PDE4 inhibitor COPD roflumilast ensifentrine

roflumilast COPD exacerbations

PMID: 38476122

ensifentrine COPD dosage FDA approved 2024 nebulization

GOLD 2025 COPD exacerbation management guidelines drug dosages

https://goldcopd.org/wp-content/uploads/2024/11/GOLD-2025-Re…

ls /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or missing"

mkdir -p /home/daytona/workspace/copd-ref && python3 -c "from reportlab.lib impo…

~/copd-ref/make_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm
from reportlab.platypus import (
    SimpleDocTemplate, Table, TableStyle, Paragraph, Spacer, HRFlowable
)
from reportlab.lib.styles import ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.platypus import KeepTogether

OUTPUT = "/home/daytona/workspace/copd-ref/COPD_Exacerbation_Quick_Reference.pdf"

# ── Colours ──────────────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1A3A5C")
MED_BLUE    = colors.HexColor("#2E6DA4")
LIGHT_BLUE  = colors.HexColor("#D6E8F7")
ACCENT_RED  = colors.HexColor("#C0392B")
ACCENT_GRN  = colors.HexColor("#1E7E34")
PALE_GREY   = colors.HexColor("#F5F5F5")
WHITE       = colors.white
GOLD_AMBER  = colors.HexColor("#F0A500")

# ── Styles ────────────────────────────────────────────────────────────────────
title_style = ParagraphStyle("title",
    fontName="Helvetica-Bold", fontSize=15, textColor=WHITE,
    alignment=TA_CENTER, spaceAfter=2)

subtitle_style = ParagraphStyle("subtitle",
    fontName="Helvetica", fontSize=8, textColor=LIGHT_BLUE,
    alignment=TA_CENTER, spaceAfter=0)

section_style = ParagraphStyle("section",
    fontName="Helvetica-Bold", fontSize=8, textColor=WHITE,
    alignment=TA_CENTER)

body = ParagraphStyle("body", fontName="Helvetica", fontSize=7.5, textColor=colors.black, leading=10)
body_bold = ParagraphStyle("body_bold", fontName="Helvetica-Bold", fontSize=7.5, textColor=DARK_BLUE, leading=10)
small = ParagraphStyle("small", fontName="Helvetica", fontSize=6.5, textColor=colors.grey, leading=9)
red_bold = ParagraphStyle("red_bold", fontName="Helvetica-Bold", fontSize=7.5, textColor=ACCENT_RED)
grn_bold = ParagraphStyle("grn_bold", fontName="Helvetica-Bold", fontSize=7.5, textColor=ACCENT_GRN)
cell_hdr = ParagraphStyle("cell_hdr", fontName="Helvetica-Bold", fontSize=7.5, textColor=WHITE, alignment=TA_CENTER)
cell_body = ParagraphStyle("cell_body", fontName="Helvetica", fontSize=7, textColor=colors.black, leading=9)
cell_bold = ParagraphStyle("cell_bold", fontName="Helvetica-Bold", fontSize=7, textColor=DARK_BLUE, leading=9)

def section_header(text, bg=MED_BLUE):
    t = Table([[Paragraph(text, section_style)]], colWidths=[175*mm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ]))
    return t

def drug_table(headers, rows, col_widths):
    data = [[Paragraph(h, cell_hdr) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), cell_body) for c in row])
    t = Table(data, colWidths=col_widths)
    style = [
        ("BACKGROUND",    (0,0), (-1,0),  DARK_BLUE),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, PALE_GREY]),
        ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#AAAAAA")),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 4),
        ("RIGHTPADDING",  (0,0), (-1,-1), 4),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ]
    t.setStyle(TableStyle(style))
    return t

# ── Document ──────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=10*mm, rightMargin=10*mm,
    topMargin=8*mm,   bottomMargin=8*mm
)

story = []

# ── HEADER BANNER ─────────────────────────────────────────────────────────────
header_data = [[
    Paragraph("COPD EXACERBATION", title_style),
    Paragraph("QUICK REFERENCE CARD", title_style),
]]
header_table = Table(header_data, colWidths=[90*mm, 85*mm])
header_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
]))
story.append(header_table)

sub_data = [[Paragraph("Based on GOLD 2025 Guidelines  |  For reference only — always apply clinical judgement", subtitle_style)]]
sub_t = Table(sub_data, colWidths=[175*mm])
sub_t.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 0),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
]))
story.append(sub_t)
story.append(Spacer(1, 2*mm))

# ────────────────────────────────────────────────────────────────────────────
# TWO-COLUMN LAYOUT via a wide Table
# ────────────────────────────────────────────────────────────────────────────
col_W = 86*mm   # each column
gap   = 3*mm

# ── LEFT COLUMN ───────────────────────────────────────────────────────────────
left = []

# 1. OXYGEN
left.append(section_header("① OXYGEN THERAPY", ACCENT_RED))
left.append(Spacer(1,1.5*mm))
left.append(Paragraph("<b>Target SpO₂: 88–92%</b>  (avoid hyperoxia → hypercapnia)", body_bold))
left.append(Spacer(1,1*mm))
oxy_rows = [
    ["Nasal cannula", "1–4 L/min", "Titrate to SpO₂ 88-92%"],
    ["Venturi mask", "24–28%", "More precise FiO₂ control"],
    ["Use <b>air-driven</b> nebulizers", "—", "Avoid O₂-driven (↑PaCO₂)"],
]
left.append(drug_table(["Device","Flow/FiO₂","Note"], oxy_rows, [32*mm, 24*mm, 30*mm]))
left.append(Paragraph("→ Check ABG at 30–60 min. Monitor for rising PaCO₂.", small))

left.append(Spacer(1,2*mm))

# 2. BRONCHODILATORS
left.append(section_header("② BRONCHODILATORS  (Start Immediately)", MED_BLUE))
left.append(Spacer(1,1.5*mm))
left.append(Paragraph("<b>SABA — First Line</b>", body_bold))
bd_rows = [
    ["Salbutamol (nebulized)", "2.5 mg q20 min × 3\nthen q1–4h PRN"],
    ["Salbutamol MDI + spacer", "4–8 puffs q1–4h PRN"],
]
left.append(drug_table(["Drug","Dose"], bd_rows, [46*mm, 40*mm]))
left.append(Spacer(1,1*mm))
left.append(Paragraph("<b>SAMA — Add if inadequate response</b>", body_bold))
sa_rows = [
    ["Ipratropium (nebulized)", "0.5 mg (500 mcg) q4–6h"],
    ["Ipratropium MDI + spacer", "4–8 puffs q4–6h"],
]
left.append(drug_table(["Drug","Dose"], sa_rows, [46*mm, 40*mm]))
left.append(Spacer(1,1*mm))
left.append(Paragraph(
    "✔ Can combine Salbutamol + Ipratropium in same nebulizer\n"
    "✔ Continue existing LABA/LAMA — do NOT stop\n"
    "✘ IV Methylxanthines (theophylline) — NOT recommended", small))

left.append(Spacer(1,2*mm))

# 3. CORTICOSTEROIDS
left.append(section_header("③ SYSTEMIC CORTICOSTEROIDS", colors.HexColor("#7B3F00")))
left.append(Spacer(1,1.5*mm))
cs_rows = [
    ["Prednisolone", "30–40 mg PO once daily", "5 days (preferred)"],
    ["Methylprednisolone", "40 mg IV once daily", "5 days if cannot take PO"],
]
left.append(drug_table(["Drug","Dose","Duration"], cs_rows, [30*mm, 33*mm, 23*mm]))
left.append(Paragraph(
    "• Oral = IV in efficacy  • No benefit > 5 days  • No taper needed for 5-day course", small))

left.append(Spacer(1,2*mm))

# INDICATORS FOR HOSPITALIZATION
left.append(section_header("⚠ ADMIT TO HOSPITAL IF", colors.HexColor("#7D3C98")))
left.append(Spacer(1,1.5*mm))
admit_items = [
    "Marked dyspnea at rest / cyanosis",
    "SpO₂ < 90% despite O₂",
    "Confusion / altered consciousness",
    "Respiratory acidosis: pH ≤ 7.35",
    "Failure to respond to initial treatment",
    "Significant comorbidities (cardiac, etc.)",
]
for item in admit_items:
    left.append(Paragraph(f"▸  {item}", body))
left.append(Spacer(1,1*mm))
left.append(Paragraph(
    "<b>ICU if:</b> pH < 7.25, persistent hypoxia, resp. arrest, hemodynamic instability",
    red_bold))

# ── RIGHT COLUMN ──────────────────────────────────────────────────────────────
right = []

# 4. ANTIBIOTICS
right.append(section_header("④ ANTIBIOTICS", ACCENT_GRN))
right.append(Spacer(1,1.5*mm))
right.append(Paragraph("<b>Indications (GOLD — any ONE below):</b>", body_bold))
right.append(Paragraph("1. Increased dyspnea + sputum volume + purulence (all 3)", body))
right.append(Paragraph("2. Increased purulence + either dyspnea OR volume", body))
right.append(Paragraph("3. Requires assisted ventilation (NIV or intubation)", body))
right.append(Spacer(1,1.5*mm))
right.append(Paragraph("<b>Standard risk (no Pseudomonas):</b>", body_bold))
ab_rows = [
    ["Azithromycin", "500 mg PO OD", "5 days"],
    ["Amoxicillin-clavulanate", "875/125 mg PO BD", "5–7 days"],
    ["Doxycycline", "100 mg PO BD", "5–7 days"],
]
right.append(drug_table(["Drug","Dose","Duration"], ab_rows, [35*mm, 28*mm, 18*mm]))
right.append(Spacer(1,1.5*mm))
right.append(Paragraph(
    "<b>High risk — Pseudomonas coverage</b>\n"
    "(severe COPD, bronchiectasis, recent hospitalization, prior Pseudomonas):", body_bold))
ab_rows2 = [
    ["Levofloxacin", "750 mg PO/IV OD", "7–10 days"],
    ["Ciprofloxacin", "400 mg IV / 750 mg PO BD", "7–10 days"],
]
right.append(drug_table(["Drug","Dose","Duration"], ab_rows2, [28*mm, 37*mm, 16*mm]))
right.append(Paragraph(
    "Post-exacerbation prophylaxis: Azithromycin 250 mg every 2 days × 3 months", small))

right.append(Spacer(1,2*mm))

# 5. NIV
right.append(section_header("⑤ NON-INVASIVE VENTILATION (BiPAP)", colors.HexColor("#1A6352")))
right.append(Spacer(1,1.5*mm))
right.append(Paragraph("<b>Indications:</b>", body_bold))
right.append(Paragraph("• pH ≤ 7.35 with PaCO₂ > 45 mmHg (respiratory acidosis)", body))
right.append(Paragraph("• Severe dyspnea + accessory muscle use / paradoxical breathing", body))
right.append(Paragraph("• Persistent hypoxia despite controlled O₂ therapy", body))
right.append(Spacer(1,1.5*mm))
niv_rows = [
    ["IPAP (inspiratory)", "10–15 cmH₂O", "Titrate up for relief"],
    ["EPAP (expiratory)", "4–5 cmH₂O", "Start low"],
    ["FiO₂", "Titrate", "SpO₂ target 88–92%"],
]
right.append(drug_table(["Parameter","Start","Goal"], niv_rows, [33*mm, 27*mm, 21*mm]))
right.append(Paragraph(
    "• NIV reduces mortality, intubation rate, ICU stay\n"
    "• Reassess in 1h — if pH worsening, escalate to intubation", small))

right.append(Spacer(1,2*mm))

# 6. SUPPORTIVE
right.append(section_header("⑥ SUPPORTIVE CARE", DARK_BLUE))
right.append(Spacer(1,1.5*mm))
sup_rows = [
    ["DVT prophylaxis", "LMWH SC (e.g. enoxaparin 40 mg OD)"],
    ["Fluid balance", "Monitor — avoid overhydration"],
    ["Nutrition", "Maintain caloric intake"],
    ["Smoking cessation", "Counsel at every admission"],
    ["Vaccinations", "Influenza + pneumococcal if due"],
]
right.append(drug_table(["Measure","Detail"], sup_rows, [32*mm, 54*mm]))

right.append(Spacer(1,2*mm))

# 7. DISCHARGE
right.append(section_header("⑦ DISCHARGE & FOLLOW-UP", GOLD_AMBER))
right.append(Spacer(1,1.5*mm))
right.append(Paragraph("<b>Safe to discharge when:</b>", body_bold))
right.append(Paragraph("• SABA needed ≤ q4h  •  Patient mobile across room", body))
right.append(Paragraph("• Eating/sleeping without major dyspnea  •  ABG stable", body))
right.append(Spacer(1,1*mm))
right.append(Paragraph("<b>Follow-up:</b>  Within 4–6 weeks", body_bold))
right.append(Paragraph("Review: inhaler technique • maintenance therapy • exacerbation triggers", body))

# ── ASSEMBLE TWO-COLUMN TABLE ─────────────────────────────────────────────────
two_col = Table([[left, right]], colWidths=[col_W, col_W])
two_col.setStyle(TableStyle([
    ("VALIGN",       (0,0), (-1,-1), "TOP"),
    ("LEFTPADDING",  (0,0), (-1,-1), 0),
    ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ("TOPPADDING",   (0,0), (-1,-1), 0),
    ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ("LINEAFTER",    (0,0), (0,-1), 0.5, colors.HexColor("#CCCCCC")),
    ("RIGHTPADDING", (0,0), (0,-1), 3),
    ("LEFTPADDING",  (1,0), (1,-1), 3),
]))
story.append(two_col)

# ── FOOTER ────────────────────────────────────────────────────────────────────
story.append(Spacer(1, 2*mm))
story.append(HRFlowable(width="100%", thickness=0.5, color=DARK_BLUE))
story.append(Spacer(1,1*mm))
footer_data = [[
    Paragraph("Sources: GOLD 2025 Report &amp; Pocket Guide | Goldman-Cecil Medicine | Rosen's Emergency Medicine | Goodman &amp; Gilman's Pharmacology", small),
    Paragraph("July 2026  |  For educational use only", small),
]]
ft = Table(footer_data, colWidths=[135*mm, 40*mm])
ft.setStyle(TableStyle([
    ("LEFTPADDING",  (0,0), (-1,-1), 0),
    ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ("TOPPADDING",   (0,0), (-1,-1), 0),
    ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ("ALIGN", (1,0), (1,0), "RIGHT"),
]))
story.append(ft)

doc.build(story)
print("PDF created:", OUTPUT)

cd /home/daytona/workspace/copd-ref && python3 make_pdf.py 2>&1