Asthma Flashcards
(191 cards)
1
Q
in what resp disorder is there a change in volume of air the lung can hold?
A
restrictive disorders
2
Q
what is obstructive resp disorders?
A
asthma & copd
- lead to a decrease in airflow
- *no change in volume of air the lungs can hold
3
Q
when are most cases of asthma diagnosed?
A
<10 years of age
4
Q
what is the definition of asthma?
A
a chronic inflammatory disorder
5
Q
what are the symptoms of asthma?
A
non-specific
-cough (may/may not be productive)
6
Q
what does the inflammation in asthma cause?
A
recurrent episodes of coughing (particularly at night or early in the morning), wheezing, breathlessness, and chest tightness
7
Q
do asthma symptoms come and go and what are they dependent on?
A
symptoms come and go and are dependent on environment (i.e. cats)
-COPD sx’s are always there
8
Q
patients with asthma symptoms need to be referred to what?
A
spirometry
9
Q
what is the hallmark feature of asthma?
A
Airflow obstruction that is at least partially <b>reversible</b>
10
Q
what does spirometry show in asthma? (what is FEV1?)
A
FEV1 of >200ml <b>and</b>
≥12% increase from baseline measure after SABA (e.g., albuterol)
11
Q
what risk factors do people with have?
A
atopic conditions (i.e. eczema, allergic rhinitis, etc.)
IgE is the antibody
12
Q
what are inhaled allergens?
A
-pollen, cockroaches, animal dander, dust mites, damp rooms (mold)
<b>IgE antibodies - specific to the type of allergen</b>
13
Q
what are inhaled irritants?
A
-perfumes, tobacco smoke, cleaning agents, airborne chemicals, wood burning stoves
universal triggers NOT associated w/IgE
14
Q
what are the preferred agents to use for inflammatory/immune response of asthma?
A
inhaled corticosteroids
15
Q
what are the monoclonal antibody medications for asthma?
A
Xolair (omalizumab), Cinqair (reslizumab), Nucala (mepolizumab)
16
Q
what is the mechanism of Cinquair (reslizumab) and Nucala (mepolizumab)?
A
block IL-5 and prevent the activation of eosinophils
17
Q
what is the mechanism of Xolair (omalizumab)?
A
specifically binds to IgE and reduces serum IgE to <5% to what it was at baseline and prevents cascade from occurring
18
Q
are the monoclonal antibodies first or last line meds for asthma?
A
LAST LINE
-for patients that are not responding to their inhaled corticosteroids, using bronchodilator frequently, having frequent flare ups and have allergic asthma worst of the worst patients
19
Q
what is the indication for Xolair (omalizumab)?
A
- 6+ years
- mod-severe asthma not controlled on ICS
- skin test or perennial allergies (animal dander, cockroaches, indoor molds, dust mites)
20
Q
what is the indication for Cinqair (reslizumab)?
A
18+ years w/severe asthma esoinophilic phenotype
21
Q
what is the indication for Nucala (mepolizumab)?
A
12+ years severe asthma w/an eosinophilic phenotype
22
Q
patients with asthma should be referred for what testing?
A
allergy testing
23
Q
how do you reduce exposure to animal dander?
A
- Keep animal(s) out of the bedroom
- Seal (filter) air ducts leading to bedroom
- HEPA Filters
24
Q
how do you reduce exposure to dust mites?
A
<b>-Reduce humidity to <50% - dust mites can’t survive if it’s too dry</b>
- Remove carpets if possible
- Wash bedding weekly (≥130oF)
- Encase mattress, pillow, and box springs in an allergen impermeable cover
25
how do you reduce exposure to cockroaches?
- Use poison bait or traps
| - Do not leave food or garbage exposed
26
how do you reduce exposure to pollens & outdoor molds?
- Use air conditioning
| - Stay indoors when pollen counts are high
27
how do you reduce exposure to indoor molds?
- Fix all water leaks
- Clean moldy surface
- Reduce humidity to <50%
28
what are common asthma triggers/exacerbating factors?
- GERD
- Rhinitis (use inhaled intranasal steroids)
- Exercise
- Sulfites
- Beta-blockers (including eye drops)
29
according to the EPR 3, if you have intermittent asthma, what txt do you need?
Intermittent asthma – not very symptomatic (have occasional issue and need albuterol; exercise induced asthma)
-don’t need to use controller therapy (only use bronchodilators)
30
according to the EPR 3, if you have persistent asthma, what txt MUST you use?
MUST use controller therapy (preferred therapy is inhaled corticosteroid)
31
what 2 domains are assessed when staging severity?
impairment & risk
32
what is the impairment domain when staging severity?
- Frequency & intensity of symptoms
- Functional limitations
- Effect on quality of life
33
what is the risk domain when staging severity?
- Future exacerbations
- Loss of pulmonary function
- Risk of adverse effects from medication
34
what are the 2 treatment goals of asthma?
- reduce impairment
| - reduce risk
35
what is the rule of 2 for treatment of asthma?
Factors that suggest asthma is not controlled:
-Using SABA >2 days/week, or waking up >2x/month, or using >2 canisters of SABA/year
36
what txt goals are for reducing impairment of asthma?
- Prevent asthma symptoms
- Require infrequent use (<2 days a week) of inhaled SABA
- Maintain (near normal pulmonary function
- Maintain normal activity levels
- Meet the patient’s expectations with asthma care
37
what txt goals are for reducing risk of asthma?
- Prevent recurrent asthma exacerbations
- Prevent loss of lung function
- Provide optimal pharmacotherapy
38
what do peak flow meters measure?
- Measures how well lungs are able to expel air (Peak expiratory flow rate or PEFR – L/min)
- Not as sensitive as a spirometer, but pts can use it to measure their lung fxn at home
-pts set their personal best over 2-3 week period & record their highest value
39
what reading do pts record when using a peak flow meter?
their HIGHEST reading (not the avg.)
40
what the clinical utility of the peak flow meters?
- Early indicator for loss of control
- May help patients identify triggers
- Determine how well regimen is working
- May help indicate when to seek emergency care
41
after a personal best with the peak flow meter is established, what is the use?
- Use at least every morning upon awakening
- Use before taking any asthma medication
- May use after taking a rescue medication to determine impact
- Use as directed by PCP*** (i.e. action plan)
42
what are the 3 zones for asthma action plans?
80-100% of Personal Best = Green zone
50-80% of Personal Best = Yellow zone
<50% of Personal Best = Red zone
43
what does the green zone indicate?
80-100% of Personal Best
- Continue with regular activities
- Follow your maintenance medication plan (no changes)
44
what does the yellow zone indicate?
50-80% of Personal Best
- May require medication adjustment
- Contact health care provider
45
what does the red zone indicate?
<50% of Personal Best
-Emergency – Dial 911
Contact Health Care Provider -> going to the hospital!!
46
if peak flow reading increases 20% or more after using a SABA, what should you consider?
adjusting controller therapy
47
how frequently should you follow up for asthma?
- Every 2-6 weeks while gaining control
- Every 1-6 months once controlled
- At 3 month intervals if a reduction in therapy is anticipated
48
what do you assess at every follow-up visit for asthma?
-Asthma control
-Medication technique
-Asthma action plan
-Medication adherence
-Patient related concerns
49
what are the top 3 risk factors for death to refer a pt for?
- Prior severe exacerbation (Intubation or ICU Admission)
- 2+ Hospitalizations or 3+ ED visits past year
- >2 canisters of SABA per month
50
when do you consider an asthma specialist?
-Hospitalized
-Difficulties achieving or maintaining control
(Step 4 care+ is required;
Step 3 care+ for kids 0-4 years)
-If immunotherapy is considered
-If additional testing is indicated
-If >2 oral steroid bursts in past year
51
what are the criteria for stepping down a pts therapy?
- Must be “well controlled” for at least 3 months
- Reduction should be gradual (i.e. decrease ICS by 25-50%)
- Must monitor closely (e.g. 2-6 weeks)
- Consider history of prior exacerbations
- Remember use the least amount of medication needed for control
52
what should you provide to all asthma patients?
asthma action plans
| -Tells patient what to do if they are starting to lose control
53
what is in an asthma action plan?
1. Daily management
- Controller medication
- Environmental control measures
2. Managing worsening asthma
- How to adjust medication
- When to see medical care
54
what are the 2 asthma medication regimens?
maintenance and rescue
55
what is the maintenance regimen for asthma?
control inflammation to some extent
- inhaled corticosteroids
- long acting B2-agonsts
- long acting anticholinergics
- leukotriene antagonists
- theophylline
56
what 2 medication categories in the asthma maintenance regimen, don't target inflammation but are in combo products?
Long acting B2-agonists (help w/bronchodilation but not inflammation)
Long acting anticholinergics (help w/bronchodilation but not inflammation)
57
what is the rescue regimen for asthma?
quick acting agents to get out of bronchoconstricted state
-Short acting B2-agonists
-***Short acting anticholinergics
(NOT approved or recommended for rescue in asthma)
58
what do MDIs have that DPIs don't have?
a propellant (HFA) that helps push medicine out
59
what are the advantages of MDIs?
- Less time (<1 min)
- Small/portable
- No drug preparation
- Mechanical ventilation
60
what are the disadvantages of MDIs?
-Technique/timing essential
- Freon effect (< w/HFA)
- Requires breath hold
- Oropharyngeal deposition
61
what are the advantages of DPIs?
-Less time (<1 min)
-Less technique/timing
-Small/portable
-Usually less money than MDI counterpart
62
what are the disadvantages of DPIs?
- Some dose preparation
- Requires breath hold
- Requires fast inhalation
- Oropharyngeal deposition
- No mechanical ventilation
63
what are the advantages of nebulizers?
- Minimal technique/timing
- No breath hold required
- Mechanical ventilation
64
what are the disadvantages of nebulizers?
- More expensive
- Drug preparation required
- Admin time (5-15min)
- Bulky and less portable
- Requires power source
- Must clean regularly
65
what is important when using an MDI?
how the pt holds it
-must hold in an "L" position (mouth piece down)
exhaling completely
breathing in deeply and slowly for 3-5 secs while depressing canister
66
who are valve holding chambers good for?
for pts w/problems coordinating and inhaling easier for patients
67
what do the valve holding chambers do?
Valves hold the medication in there, so gives you a little extra time to inhale
(vs spacers, just gives you space and doesn’t hold anything)
valves are better
68
are MDIs & DPIs compatible with valve holding chambers & spacers?
only MDIs are
69
if a kid uses a facemask, what should the parents make sure to do?
make sure kids wash around their mouth b/c it will lead to atrophy of skin around mouth
70
what is it about valve holding chambers (VHC)?
- Requires less coordination to use
- Improves drug deposition into lungs
- Decreases oropharyngeal deposition
- Consider a face mask in child < 4 years old
- Use one actuation per inhalation!!!!!
71
what should every patient with asthma have?
a SABA
72
what is quick relief medication for asthma?
a SABA
73
what is the mechanism for SABAs?
increases adenyl cyclase -> increases cAMP which activates PKA -> Ca++ leaves the cell -> smooth muscle relaxes
74
when do pts use SABAs?
-Acute symptoms and exacerbations
| -Treatment of choice for exercise induced asthma
75
what medication is the treatment of choice for exercise induced asthma?
SABAs
76
what is recommended for cleaning of SABAs?
Weekly cleaning is recommended
77
what is NOT recommended when using SABAs?
Regularly scheduled, daily, chronic use is NOT recommended
78
what is albuterol?
a SABA
79
what is levalbuterol?
SABA
brand name = Xopenex HFA
80
what is the respiclick device?
a DPI
81
what is the indication for the respiclick device?
- Treatment or prevention of bronchospasm in 4 years+
| - Prevention of exercise-induced bronchospasm in 4 years+
82
what are the features of the respiclick device?
- Dose counter (even numbers only)
- “Click” open ~ loads dose
- No priming or cleaning required
- Breath activated device (Dry Powder)
83
are nebulizers preferred in a conscious pt?
NO! they are NEVER preferred in a conscious pt (no added benefit)
-will lean towards MDI & VHCs more w/outpatient/discharging pts
84
what percentage of albuterol is pre-mixed w/saline?
albuterol sulfate 0.083% (2.5mg/3ml)
-for albuterol sulfa 0.5% you must co-prescribe saline with it
85
what is beclomethasone HFA?
ICS
86
what is budesonide DPI?
ICS
87
what is budesonide Neb?
ICS
88
what is flunisolide HFA?
ICS
89
what is fluticasone HFA?
ICS
90
what is mometasone DPI?
ICS
91
what is ciclesonide HFA?
ICS
92
when are inhaled corticosteroids (ICS) used?
Preferred long-term control therapy for all ages
93
how often should you clean ICS?
weekly cleaning
94
what should a pt do after using an ICS?
rinse mouth and expectorate after using
- use prior to brushing teeth
- wash around child's mouth if using a mask!
95
mild-mod asthma is managed with what dose of ICS?
low-medium ICS doses
96
what do ICS improve and provide reduced need of?
Improves lung function and reduced need for quick relief medications
97
what is fluticasone propionate?
ICS
98
what is fluticasone furoate?
ICS
99
what are the adrs of ICS?
-oral candidiasis
-dysphonia
-reflex cough and bronchospasm
-growth rates are variable in children
100
how do you reduce the oral candidiasis and dysphonia - adrs of ICS?
spacer, rinsing mouth, decrease dose/freq (if possible)
101
how do you reduce the reflex cough and bronchospasm air of ICS?
Spacer, decrease rate of inspiration, pre-treat with albuterol
102
what is the only pregnancy category B ICS? when should you use it?
budesonide (Pulmicort Flexhaler)
-if initiating therapy & pt is pregnant then may use budesonide, but don't change if pt is on budesonide and then becomes pregnant
103
what is the exception for cleaning MDI weekly?
Aerospan (flunisolide) b/c has spacer
104
what is annuity ellipta? chemical name? clinical pearls?
DPI
Chemical name: fluticasone furoate
Clinical pearls:
- 1st once daily ICS
- cleaning not required
- unable to double load dose
- discard 6 wks after opening tray
105
what are the drawbacks of annuity ellipta?
- See DPI limitations
| - Dosing may be less flexible
106
what is armonair respiclick?
DPI
Chemical Name: Fluticasone propionate (ICS)
Clinical Pearls:
- 12+ Asthma maintenance
- Not interchangeable with Flovent!
- Unable to double load dose
- Discard 30 days after opening
107
what are the oral corticosteroids?
- methylprednisolone
- prednisolone
- prednisone
108
when should you burst a patient?
when a patient is losing control & in the yellow zone
109
what does to burst a patient mean?
a temporary increase in anti-inflammatory therapy -> to reestablish asthma control
110
what MUST long acting B2-agonists be used with?
MUST BE used with anti-inflammatory medications (ICS) for long-term control of asthma symptoms
111
what can long acting B2-agonist be used to prevent?
Can be used to prevent exercise-induced bronchospasm (30min-1hr before activity)
-but PREFERRED for exercise-induced bronchospasm is SABA
112
what should long acting B2-agonists NOT be used to treat?
Not to be used to treat acute symptoms or exacerbations
113
what is a long acting B2-agonist (LABA)?
salmeterol (Servant Diskus)
114
what is Breo Ellipta? Chemical name? Clinical pearls? drawbacks?
DPI
ONE INHALATION A DAY!!!
Chemical Name: fluticasone furoate + vilanterol
```
Clinical Pearls:
-1st once daily/ICS/LABA Combo
-Cleaning not required
-Unable to double load dose
-Discard 6 weeks after opening tray
```
Potential Drawbacks:
-See DPI limitations
**Only strength FDA approved for COPD
115
how often do you inhale bro ellipta?
ONE INHALATION A DAY
116
what is Airduo Respiclick? Chemical name? Clinical pearls?
DPI
Chemical Name: fluticasone propionate + salmeterol
(ICS + LABA)
Clinical Pearls:
- 12+ Asthma maintenance not controlled on ICS alone
- Not interchangeable with Advair!
- Unable to double load dose
- Discard 30 days after opening
117
what is a long acting antimuscarinic (LAMA)?
Spiriva Respimat (tiotropium)
118
when do you use Spiriva Respimat (tiotropium) (long acting antimuscarinic?
Add on txt for pts with a history of exacerbations (need ICS onboard also)
-Good for patients that are on LABA and ICS and aren’t responding then add on Spiriva
Once-daily, maintenance txt of asthma in pts 6+ years
119
what are the clinical pearls of Spiriva Respimat (tiotropium) (long acting antimuscarinic)?
- EXPENSIVE
- Expires 90 days after loading
- Dose = Two half turns once daily
- Spiriva (tiotropium) Respimat is only LAMA approved for asthma
120
what are drawbacks of Spiriva Respimat (tiotropium) (long acting antimuscarinic)?
- Initial load and priming
| - Coordination b/w dose release and inhalation
121
is theophylline used a lot?
Not used must – many DDIs, monitoring, narrow therapeutic index
122
when do you use theophylline?
- Alternative therapy for Step 2 care (not preferred)
| - Adjunctive therapy with ICS in patients ≥ 5 years old
123
what must you monitor with theophylline?
Monitor serum theophylline concentration (5-15mcg)
124
what is theophylline similar to?
it's similar to caffeine
125
what CYP enzyme does Theophylline interact with? what about smoking?
DDIs with CYP1A2
Smoking induces metabolism!
-If pt stops smoking -> theophylline dose can go very high and then need to reduce their dose
126
what are dose-related acute toxicities of theophylline?
- Tachyarrhythmias
- Central nervous system stimulation
- Seizures
- Hyperglycemia and hypokalemia
127
what is the MOA of theophylline?
Bronchodilation smooth muscle relaxation from phosphodiesterase inhibition and possible adenosine antagonism
128
what inhibitors does theophylline interact with and what happens to the levels of theophylline?
Inhibitors will INCREASE theophylline levels
- ETOH
- Zileuton
- Cimetidine
- Zafirlukast
- Propranolol
- Ciprofloxacin
129
what inducers does theophylline interact with and what happens to the levels of theophylline?
Inducers will DECREASE theophylline levels
- Smoking
- Rifampin
- Phenytoin
- Omeprazole
- Phenobarbital
- Carbamazepine
130
what are leukotrienes?
- Produced and released from multiple sources
- Contract smooth muscle (potent bronchoconstrictors – in asthma want to block leukotrienes)
- Increase vascular permeability and mucus secretions
131
when do you use leukotriene inhibitors?
- Alternative therapy for Step 2 care (not preferred)
| - Adjunctive therapy with ICS
132
what are the names of the leukotriene inhibitors?
- montelukast (Singulair) - preferred
- zafirlukast (Accolate)
- zileuton (Zyflo and Zyflo CR)
133
where do montelukast (Singulair) & zafirlukast (Accolate) block leukotrienes?
block at receptor level (LTRA)
134
where does zileuton (Zyflo) block leukotrienes?
blocks production (5-lipoxygenase inhibitor)
135
when must you take zafirlukast (Accolate)? what is its MOA? what is CYP is it an inhibitor of & what does it increase?
-Selective competitive inhibitor of LTD4 and LTE4 receptors
-Take at least 1 hour before or 2 hours after meals (b/c food can effect its bioavailability)
-Competitive inhibitor of the CYP2C9 (increases warfarin levels)
136
what is the preferred leukotriene inhibitor?
montelukast (Singulair)
137
how often do you administer montelukast (Singulair)? what is it a selective competitive inhibitor of?
-Selective competitive leukotriene D4 inhibitor
-Administer once daily at bedtime
138
what must you monitor for zileuton (Zyflo)?
liver fxn for liver toxicity!
139
what is the name of the drug that's a mast cell stabilizer?
```
cromolyn sodium (Intal)
-Nebulizer formulation ONLY
```
140
what formulation does cromolyn sodium (Intal) come in?
Nebulizer ONLY
141
when is cromolyn sodium (Intal) used? how is it dosed?
- Long-term prevention of symptoms in mild persistent asthma
- Preventative treatment prior to exercise or known allergies
-Dosed 3-4x/day
142
what are the adrs of cromolyn sodium?
- Bad taste – metallic taste
| - Cough/irritation
143
what is an add of leukotriene inhibitors?
weird dreams - just monitor if occur
144
what vaccines must everyone with asthma get?
Everyone needs yearly influenza vaccination
- trivalent or quadrivalent inactivated influenza vaccine
- Inactivated influenza vaccine, trivalent, High Dose ≥ 65 years
Everyone needs Pneumococcal vaccine
145
what is Proventil HFA, ProAir RespiClick, ProAir HFA, Ventolin HFA?
Albuterol (SABA)
146
what is QVAR?
ICS
147
what is Pulmicort Flexhaler?
ICS
148
what is Pulmicort Respules?
ICS
149
what is Aerospan?
ICS
150
what is Flovent HFA/Flowvent Diskus?
ICS
151
what is Asmanex Twisthaler?
ICS
152
what is Alvesco?
ICS
153
what is Flovent?
ICS
154
what is Arnuity?
ICS
155
what is salmeterol?
LABA
156
what is (Servant Diskus)?
LABA
157
what is fluticasone + salmeterol
ICS + LABA
158
what is Advair Diskus?
ICS + LABA
159
what is Advair HFA?
ICS + LABA
160
whites budesonide + formoterol?
ICS + LABA
161
wat is Symbicort HFA?
ICS + LABA
162
what is mometasone + formoterol?
ICS + LABA
163
what is Dulera HFA?
ICS + LABA
164
what is Spiriva Respimat?
LAMA
165
what is tiotropium?
LAMA
166
what is beclomethasone HFA generic name and drug?
QVAR (ICS)
167
what is budesonide DPI generic name and drug?
Pulmicort flexhaler (ICS)
168
what is QVAR generic name?
beclomethason (ICS)
169
what is pulmicort flexhaler?
budesonide (ICS)
170
what is budesonide Neb?
pulmicort respules (ICS)
171
what is pulmicort respules?
budesonide Neb (ICS)
172
what is flunisolide HFA?
Aerospan (ICS)
173
what is Aerospan?
flunisolide (ICS)
174
what is fluticasone HFA?
Flovent HFA/Flovent diskus
175
what is Flovent HFA/Flovent diskus?
fluticasone HFA
176
what is mometasone DPI?
Asmanex Twisthaler
177
what is Asmanex Twisthaler?
mometasone DPI (ICS)
178
what is ciclesonide HFA?
Alvesco (ICS)
179
what is Alvesco?
ciclesonide HFA (ICS)
180
what is serevant diskus?
salmeterol (LABA)
181
what is salmeterol?
serevant diskus (LABA)
182
what is advair diskus/HFA?
fluticasone + salmeterol (ICS + LABA)
183
what is fluticasone + salmeterol?
advair diskus/HFA (ICS + LABA)
184
what is symbicort HFA?
budesonside + formoterol (ICS + LABA)
185
what is budesonide + formoterol?
symbicort HFA (ICS + LABA)
186
what is dulera HFA?
mometasone + formoterol (ICS + LABA)
187
what is mometasone + formoterol?
dulera HFA (ICS + LABA)
188
what is breo ellipta?
fluticasone furoate + vilanterol (ICS + LABA)
189
what is fluticasone furoate + vilanterol?
breo ellipta (ICS + LABA)
190
what is spiriva respimat?
tiotropium (LAMA)
191
what is tiotropium?
spiriva respimat (LAMA)
