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Pharm 2 > Obstructive lung disease > Flashcards

Obstructive lung disease Flashcards

1
Q

Asthma overview

A

Heterogenous disease w/ chronic REVERSIBLE inflammation of the airways
-traffic pollution 13% global asthma
Triggers: exercise, allergen irritant exposure, change in weather, laugher, or viral infection
Associated conditions: atopy (hypersens), obesity, GERD, OSA (obstructive sleep apnea)

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2
Q

Dx of Asthma- BEEPS

A

No Gold standard
-Blood tests-> eosinophilia, elevated IgE
-Spirometry w/ methacholine
-FEV1/FVC
-PEV
-Exercise challenge test- FEV1
-Chest XRAY exclusion

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3
Q

Tx depending on severity and classification

A

Children:
Intermediate: no night time
Mild: more than 2 days a week
Mod: daily symptoms
Severe: daily, nightly, and impair ADL

Adults:
intermittent: less than or equal to 2 days
Mild: over 2 days but not daily
Mod: Daily
Severe: throughout day w/ adl impairment

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4
Q

Lifestyle changes and preventative

A
  1. Physical activity, weight loss, smoking cessation, avoidance of irritants (cosmetology school), emotional stress
  2. avoid occupational exposure
  3. annual influenza and covid 10 vacc
  4. recommended pneumococcal vacc
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5
Q

asthma Tx overview

A

Intermittent: no daily control
1. Albuterol PRN rescue
2. PRN low-dose inhaled corticosteroid

Mild persistent:
1. Low-dose inhaled corticosteroid- daily
2. Albuterol PRN rescue
3. theophylline, mast cell stabilizer, or leukotriene modifier

Moderate persistent:
1. low-medium dose inhaled glucocort + Long acting inhaled beta agonist (LABA)
2. add LAMA
3. Albuterol rescue
4. theophylline, high dose inhaled glucocort, leukotrien mod

Severe:
1. High dose inhaled corticosteroid + LABA
2. theophylline and leukotriene
3. oral steroids
4. SAMA or LAMA

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6
Q

Bronchodilators

A

Beta3=2 agonist, Bronchoselective-> work w/ Calcium to produce SM relaxation
Short acting, water soluble: Isoproterenol, albuterol/levalbuterol
long, lipid soluble, more bronchoselective: Formoterol, salmeterol, indacaterol, olodaterol, vilanterol

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7
Q

Short acting bronchodilators

A
  1. Albuterol nebulized
  2. Albuterol MDI (ProAir HFA/ Proventil HFA/ Ventolin HFA)
  3. Levalbuterol nebulized (Xopenex)- twice as potent as albuterol
  4. Levalbuterol MDI (Zopenex HFA)

epi is a SABA- but alpha agonist as well so = whole body

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8
Q

Delivery devices

A

MDI- metered dose inhaler- 50% of med gets in
DPI- dry powder inhaler- 30% of med gets in
Nebulizers- 15%

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9
Q

MDI- test q

A

inspiratory: slow and deep, hold breath, priming and shaking bottle

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10
Q

DPI- test q

A

Deep forceful inhale= QUICK

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11
Q

Long-acting Bronchodilators

A

NEVER SOLO FOR ASTHMA PTS
LABAS = >12
1. Formoterol
2. Salmeterol
Ultra LABAs = >24
indacterol, vilanterol, olodaterol

SE: asthma related death, bronchospasm, asthma exacerbation, anaphylaxis, HTN, angina, cardiac arrest, arrhythmia, hypkalemia, hypotension, hyperglycemia

HIGHER MORTALITY IF USED SOLO

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12
Q

Why are corticosteroids so important in asthma? HERM

A

TO START EARLY
1. Increasing # of Beta 2 adrenergic receptors and improving the receptor responsiveness to beta 2 adrenergic stimulation
2. Reduce mucus and hypersecretion
3. Reduce bronchial hyperresponsiveness (wheezing, breathlessness, chest tightness, coughing)
4. Reduce airway edema and exudation

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13
Q

Systemic corticosteroids

A
  1. all pts w/ acute severe asthma exacerbation not responding to inhaled cortic
    -START W/IN 1 HR OF ED SETTING TO REDUCE HOSPITALIZATION
    -ADULTS 5-7 DAYS OR KIDS 3 DAYS
  2. tapering unnecessary after improvement IF CONTINUING INHALED CORTICOSTEROIDS

1 burst in ED-> 8 burst of prednisone is equal to steroids every other day for a year= effect on bones & SE

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14
Q

Inhaled corticosteroids

A

Most improve in first 1-2 wks-> max improvement in 4-8 wks
-improvement in baseline FEV1 and PEF @ 3-6 wk mark
Dosing:
mild: once a day
Mod: twice
Severe: multiple daily

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15
Q

Anticholinergics- Reverse Bronchoconstriction

A

MOA: inhibitors of muscarinic receptors
1. Ipratropium bromide= nonselective antagonist of M1, M2, M3 receptors-> ADJUNCT THERAPY in acute severe asthma-> inhaled in ED to reduce hospitalizaiton
2. Tiotropium Bromide-> higher affinity for muscarinic receptors and dissociates more slowly-> long acting, duration of 24 hrs

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16
Q

Leukotriene modifiers- block synth of leukotrienes

A

reduce: allergen, exercise, cold air hypervent, irritant, and aspirin induced asthma
IMPROVE PULMONARY FXN TESTS (FEV1 AND PEF)-> DECREASE NOCTURNAL AWAKENINGS AND bETA 2 AGONIST USE AND IMPROVE ASTHMA SYMPTOMS
1. Montelukast (singulair)- Cysteinyl leukotriene receptor antagonist
2. Zafirlukast- cysteinyl leukotriene receptor antagonist
3. Zileuton- one 5-lipoxygenase inhibitor-> MAJOR high Liver enzymes and drug interactions w/ CYP

SE: CHURG-STRAUSS SYNDROME= asthma/hayfever, EOSINOPHILIA-> CAUSE OR MASK ASTHMA?, neuropsychiatric AE (CHILDREN AGGRESSIVENESS, IRRITABILITY, SLEEP DISTURBANCE), hepatic dysfxn/failure

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17
Q

Biologics

A
  1. Anti-IgE- Omalizumab (Xolair)
    2.Anti-IL 5 Mepolizumab (Nucala), Reslizumab (Cinqair), Benralizumab
  2. Anti-IL4/IL13 Dupilumab (Dupixent)
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18
Q

Children and Pregnancy

A

Children: Montelukast-> double dose instead of adding LABA
Pregnancy: Budesonide
MG sulfate- Magnesium-> iv or nebul for kids= SINGLE 2 G IV INFUSION UPON ED ARRIVAL
Theophylline- rarely used due to the high risk of severe life-threatening toxicity (n/v, tachy, abd pain)
Ketamine-for intubation asthmatic pts-> inhibit histamine and acetylcholine-induced bronchoconstriciton

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19
Q

Status asthmaticus or Severe Asthma Attack- BOSE MK

A
  1. Beta 2 agonists and steroids
  2. O2
  3. Oral steroids
  4. Epinephrine (if due to anaphylaxis)
  5. IV or Nebulized MgSO4
  6. Ketamine if intubation
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20
Q

COPD

A

Defined: presence of CHRONIC AIRFLOW OBSTRUCTION, determined by spirometry that usually occurs in the setting of noxious environmental exposures- MC CIGARETTE SMOKING- but doesnt have to smoke
- combo of emphysema, chronic bronchitis, small airway disease-> NOT REVERSIBLE
Sxs: cough, sputum production, dyspnea
HALLMARK: REDUCTION IN FEV1 AND FEV1/FVC
Guidelines: test for ALPHA-1 AT DEFICIENCY IN ALL SUBJECTS W/ COPD or asthma w/ chronic airglow obstruction

pfts to diagnose staging

21
Q

Asthma vs COPD

A

Asthma
-recognized
-dyspnea w/ bronchospasm
-FULLY REVERSIBLE w/ bronchodilators
-NOT GENERALLY PROGRESSIVE except in more severe
-frequent change in status

COPD
-underrecognized/undertxt
-dyspnea w/ exertion
-RESPONSIVE BUT NOT FULLY REVERSIBLE W/ BRONCHODIL
-PROGRESSIVE OVER TIME
-no changes over time except for progression

22
Q

nonpharm therapy

A
  1. SMOKING CESSATION-> WILL STOP COPD PROGRESSION
  2. limit environmental hazards and airborne exposures
  3. Pulmonary rehab- exercise training, even high intensity
  4. Long-term oxygen therapy-> resting PaO2 under 55, lower mortality if atleast 5 years of use, Nasal cannula at 1-2 l/min
  5. Vaccines: influenza, covid, PPSV23, PCV13
23
Q

Gold criteria- COPD diagnosis

A
  1. FEV1>80 = 0-1 exacerbations per year
  2. FEV1>50 but <80 = 0-1 exacerbations per year
  3. FEV1>30 but <50 = >2 exacerbations per year, or 1 hospitalizations
  4. FEV1<30= <2 exacerbations per year and <1 hospitalizations
24
Q

COPD tx

A
  1. SABA PRIN and Anticholinergic PRN
  2. LABA or LAMA and SABA PRN
  3. Inhaled corticosteroid plus LABA or LAMA, supplemental oxygen, pulmonary rehab, SABA PRN, LAMA+LABA
  4. Inhaled corticosteroid plus LABA, LAMA, pulmonary rehab, supplemental oxygen, LABA/LAMA combo, LAMA/LABA/ICS triple combo, continuous Azithromycin

NEVER USE CORTICOSTEROID ALONE= COPD
NEVER LABA= ASTHMA

25
Q

COMBOS- pick one w/ lowest dose & work up

A
26
Q

Phosphodiesterase inhibitors PDE4

A

PDE4 found in airway sm cells, inflam cells, responsible for degrading intracellular cAMP
1. Roflumilast
-for pts w/ recurrent exacerbations despite tx w/ triple therapy or pts who are on dual therapy and not a candidate for ICS
-DO NOT GIVE IN CONJUNCTION W/ THEOPHYLLINE
-SE: DIARRHEA, NEUROPSYCHIATRIC (suicide, insomnia, anxiety, depression)
-low and slow
-drug interactions: CYP p450

27
Q

Azithromycin

A

250 MG daily
chronic tx- lower rate of exacerbations-> improved quality of life scores
Drawbacks: hearing deficits, colonization of macrolide resis bacteria, QT prolongation

ADD AZITH FOR PTS W/ RECURRENT EXACERBATIONS DESPITE OPTIMAL THERAPY AND ARE NOT ACTIVE SMOKERS

28
Q

other pharm therapies

A
  1. alpha trypsin replacement therapy- for INHERITED AAT deficiency associated emphysema-> weekly infusions of pooled human AAT to maintain levels over 10 micromole/L-> expensive
  2. Expectorants and mucolytics-> high dose to be effective
  3. Opioids-> morphine to relieve dyspnea in pts w/ end-stage COPD
29
Q

Lung section

A

here we go

30
Q

Infections of lung and resp system

A
  1. acute epiglottitis
  2. Croup
  3. Bronchiolitis
  4. Pertussis
  5. Pneumonia
  6. Tuberculosis
  7. COPD exacerbation
31
Q

Acute epiglottitis

A

Risk: non-vacc kids
Organism: H. flu -> get vacc
Sxs: muffled voice, tripoding, drooling, fever, distress
Xray: thumb sign
Complications: severe life-threatening due to risk of sudden airway compromise-> secure airway
tx:
1. secure airway
2. 3rd gen Cephalosporin (ceftriazone) + antistaph (vancomycin)

32
Q

Laryngotracheobronchitis aka Croup

A

risk: kids
organism: Parainfluenza
sxs: seal bark cough that improves w/ exposure to cold air, URI sxs with STRIDOR, congestion, URI
Xray: Steeple sign
complications: respiratory failure
Tx:
1. mild - humid air/symptomatic care + dexamethasone 1 dose 0.6 mg/kg max of 12 mg
2. Mod- steroids, dexa IV, IM, PO
3. Severe- racemic epinephrine (Nebulized)- only if resp failure, STRIDOR @ REST-> MUST WATCH FOR 2-3 HOURS BC REBOUND EFFECT

Westley croup severity score: stridor, retractions, blue lips

33
Q

Bronchiolitis

A

risk: kids 2 and younger
organism: RSV
sxs: URI sx w/ fever and wheezing, nasal flaring, tachypnea, retractions, low O2 stats, move to LRI
Tx: NO STEROIDS
-mild: hydration, NASAL SUCTION BULB, monitor
-Mod to severe: nasal suction, hydration, oxygen, one time trial of inhaled bronchodilators, do not use oral glucocort

34
Q

Pertussis aka Whooping cough

A

organism: Bordetella pertussis
Sxs: prolonged cough >2 weeks, inspiratory “whoop” w/ paroxysmal cough, pot-tussive emesis
tx: reduces spread - doesnt shorten the course
-azithromycin if onset of cough w.in past 6 wks
- and if onset w/ in 3 wks
no abx if no onset of cough

Immunization:
younger kids: DTAP- diphtheria toxoid, tetanus toxoid, the pertussis vaccine -> 5 dose series= 2, 4, 6, 15-18, and 4-6 yrs of age
older kids: TDAP- tetanus toxoid, reduced diphtheria toxoid, pertussis
single boost from 11-12 and every 10 year intervals

35
Q

Pneumonia

A
  1. Community-Acquired pneumonia
  2. Hospital-acquired pneumonia
  3. Ventilator-associated pneumonia
36
Q

CAP empiric tx outpatient

A

comorbities:
-penicillin allergy= cephalosporin + macrolide
-no pen allergy= Augmentin plus azithro
-no allergy but COPD= Fluoro

No comorb:
5 days tx penicillins, augmentin, macrolides, tetracyclines,

37
Q

HAP or VAP tx

A

hap= occurs after 48 hrs or more after admission not at admission
vap= type of HAP develops more than 48 hours after endotracheal intubation

tx:
recent abx use?
resident flora and resis rates in hospital or ICU-> sputum cultre
increased mortality-> underlying diseases or severity of illness
available cultures or gram stains?
risk for MRSA or MDR - multidrug res

recommended tx:
Piperacillin-tazobactam
Cefepime
Levofloxacin
Imipenem
Meropenem

38
Q

Special Pneumonia

A

fungal: histoplasmosis or blastomycosis -> tx: Itraconazole or alt amphotericin B

HIV related: pneumocystitis jirovecii -> tx: Bactrim x 21 days

39
Q

Pneumonia vaccines

A

indications:
>65 yoa
19-64 yoa w/ chronic heart, lung, liver disease, immunocompromised, or impaired splenic fxn

2 vacc:
Pneumococcal polysaccharide vaccine (PPSV)- Pneumovax
Pneumococcal conjugate vaccine (PCV)- Prevnar

Prevnare 1 yr then Pneumovax

40
Q

PPSV

A

IM or SQ
1 dose
23- valent pneumococcal polysaccharides
AB response wanes over time-> pt may need revacc depending on comorb
EVERY 5-10 YRS

41
Q

PCV

A

IM
Prevnar13 mc-> 13 capsular types
linked to protein-> helps body to produce ab
4 dose series after birth- 2, 4, 6, 12-15 months

42
Q

TB tx review

A

Latent tb- short course of rifamycin based 2-4 month regimen
active tb- rifampin, isoniazid, pyrazinamide, ethambutol

prego? NO STREPTOMYCIN, PYRAZINAMIDE

43
Q

COPD exacerbation overview

A

tx settings: outpatient or inpatient

RF for poor clinical outcomes:
-comorb conditions: HF, ischemic heart disease, uncontrolled HTN, uncontrolled lipidemia
-severe underlying COPD (PEV1 <50%)
- >2 exacerbations per yr
-hospitalization for an exacerbation in past 3 months
- receipt of continuous O2
- >65 yrs

Ris for infection w/ Pseudomonas:
-chronic colonization or previous isolation of pseudomonas from sputum
-very severe COPD (FEV1 <30%)
-Bronchiectasis on chest imaging
-broad spec abx use in past 3 months
-chronic systemic glucocort use

44
Q

COPD exacerbation empiric tx- Outpatient

A

target: haemophilus influenzae, moraxella catarrhalis, streptococcus pneumoniae

  1. No RF of poor outcomes or pseudomonas
    -Macrolide - azithromycin, clarithromycin
    -2nd or 3rd gen cephalosporin- cefuroxime, cefpodoxime, cefdinir
  2. RF for poor outcome, NO risk pseudomonas:
    -Augmentin
    -resp fluoroquinolone
  3. RF for both:
    Ciprofloxacin

Duration: tx for 5 days

45
Q

COPD exacerbation empiric tx- Inpatient

A

target: coinfections of previous organisms, atypical bacteria, resistant bacteria
1. No risk for pseduomonas- OR
-respiratory fluoroquinolone
-3rd gen cephalosporin- ceftriaxone or cefotaxime

  1. risk for pseudomonas- all ORs
    -Cefepime
    -ceftazidime
    -Pipercillin- tazobactam

tx: 5-7 days
other considerations:
-greater than or equal to 2 exacerbations-> may consider MACROLIDE PROPHYLAXIS
-Azithromycin= daily if exacerbations

46
Q

Effects of smoking

A

Damaging effects to nearly every organ of the body
LEADING CAUSE OF PREVENTABLE disease, disability, and death in US

3 leading:
1. lung cancer
2. chronic obstructive pulmonary disease
3. ischemic heart disease

47
Q

Nicotine effects on the body

A

blood- increase clotting
Lungs- bronchospasm
Muscular- tremor, pain
GI- nausea, dry mouth, dyspepsia, diarrhea, heartburn
Joints- pain
Central- lightheadedness, headache, sleep disturbances, abnormal dreams, irritability, dizziness
Heart: increased or decreased HR, increased BP, tachycardia, more or less arrhythmias, coronary artery constriction
Endocrine- hyperinsulinemia, insulin resistance

48
Q

Why is it difficult to quit?

A
  1. Nicotine stimulates DOPAMINE in the “reward” center-> feeling of pleasure and relaxation
  2. CAN DEVELOP WITHDRAWAL SYMPTOMS W/IN 24 HOURS-> PEAK W/IN FIRST 3 DAYS AND MAY TAKE WEEKS TO SUBSIDE

quickly reversed w/ nicotine

49
Q

Questions:

A

tx of acute exacerbation of COPD= SABA
good outcome of pharm in chronic COPD= REDUCE EXACERBATIONS
MDI-> DPI= rapid forceful inhalation
Gold stage 1 pharm strategy= Bronchodilator
lower risk of exacerbation COPD= LAMA
Roflumilast PE= PDE 4= SE= GI nausea
lower progressive decline in fxn= SMOKING CESSATION

Pharm 2 (15 decks)

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