Asthma: Chronic Care

Question 1

Asthma

Answer 1

-Esoinophilic action in lungs, allergic reaction, and IgE -airway hypersresponsiveness -inflammation (cells, chemicals) -airway obstruction

Question 2

Airflow Limitation

Answer 2

-bronchoconstriction -airwayhyperresponsiveness -airway edema (may not feel ) -airway remodeling

Question 3

Mild Intermittent Asthma

Answer 3

-1-2 / wk -exercise, cold -rescue inhaler prn -less than 2x a month at night -no limitation -FEV>80%

Question 4

Mild Persistent Asthma

Answer 4

-greater than 2x week but not daily -3 or 4b times a month at night -not everyday -not constant -minor limitation -FEV80% -low dose ICS or alternative

Question 5

Moderate Persistent

Answer 5

-everyday, but not continous -once a week at night -some limitation -combined ICS + LABA -FEV 60-80% -young child medium to high dose ICS + Leuktriene Antogonist

Question 6

Severe Persistent

Answer 6

-continuous daily -2 or more times a week at night -extremely limited

Question 7

Asthma Classifictions

Answer 7

-Intermittent: Step 1 -Mild: Step 2 -Persistent Moderate: Step 3 or 4 Severe: Step 5 or 6

Question 8

Off Medication

Answer 8

Assess severity, assign step, and perscribe meds

Question 9

On Medication

Answer 9

-Work Backwards -Assign step and severity based on medication

Question 10

Drugs and Asthma

Answer 10

-Non-selective Beta Blockers -Sulfites or food allergies -ASA/NSAID sensitivity

Question 11

Asthma Follow up

Answer 11

-assess control and step up or down -assess, treat, and eliminate comorbidities and complicating factors

Question 12

Asthma Treatment Goals

Answer 12

-prevent and control A symptoms -improve quality of life -reduce frequency and severity of exacerbations -reverse air flow obstruction

Question 13

Asthma vs COPD

Answer 13

-Asthma: Brochospasm Reversible Airways affected -COPD: Bronchospasm Irreversible Airways and Parenchyma affected More cell destruction

Question 14

COPD Classification

Answer 14

-C and D worst -Gold 3 and 4 worst

Question 15

COPD Goals

Answer 15

-relieve symptoms -improve exercise tolerance (exercise is therapy) -improve health status and prevent disease progression -treat exacerbations -reduce mortality

Question 16

COPD

Answer 16

-progressive decline in lung function -common, preventable, treatable -exacerbations

Question 17

Forms of COPD

Answer 17

-Chronic Bronchitis: chromic cough for 3 months in two consecutive years -Emphysema: abnormal and permanent enlargement of airspaces, destruction of air space walls -Asthma: chronic inflammation, reversible

Question 18

COPD Patho

Answer 18

-airway abnormalities -lung parachyma abnormalities -pulmonary vasculature

Question 19

COPD Risk Assessment

Answer 19

-Low: 1 or less excerbations per year, no hospital, Gold 1 or 2 -High: two or more excerbations per year, one or more hodpitalizations

Question 20

COPD Goals

Answer 20

-relieve symptoms -improve exercise intolerance -improve health status -prevent disease progression -prevent and treat excerbations -reduce mortality -reduce treatment side effects

Question 21

Long Term Control

Answer 21

-Corticosteroids (inhaled or po) -Cromplyn Sodium and Nedocromil -Immunodilarors (Xolair) -Leukotrine Modifiers (Singulair) -Long Acting Beta Agonists -Methylxanthines (Theophylline) -Combined Meds: ICS + LABA

Question 22

Quick Relief

Answer 22

-Anticholinergics (Atrovent) -Short-acting beta agonists (albuterol) -Systemic corticosteroids -Combined form of Atrovent and albuterol (Duoneb or Combivent)

Question 23

For COPD Only

Answer 23

-Phosphodiesterase-4 inhibitor (Roflumilast) (Long) -Carbocysteine (NA)

Question 24

Inhaled Cortiscosteroids ICS

Answer 24

-Brand names Pulmicort, Flovent, Asmanex, QVAR, Alvesco, Aerobid, etc. -ICSs are the most potent and consistently effective long-control medication for asthma -Suppress generation of cytokines, recruitment of eosinophils, and release of inflammatory mediators -Less bioavailable (more localized) than oral steroids so fewer side effects -not all steroids equal -works on many cells -decrease severity and prevent excerbations

Question 25

Inhaled Gluticosteroids in COPD

Answer 25

-Reduce inflammation in the airways -Reduce exacerbations -Possibly slow the progression of respiratory symptoms -Have little effect on altering lung function -Not to be used alone in treating COPD -Combined with bronchodilators (LABA), in advanced COPD -GOLD stages C and D

Question 26

ICS

Answer 26

-Decrease severity of symptoms -Increase quality of life -Increase PEF and spirometry -Decrease airway hyperresponsiveness -Prevent exacerbations: fewer oral steroid courses, ER visits, hospitalizations, and deaths -Attenuate loss of lung function in adults

Question 27

Decrease Effectiveness of ICS

Answer 27

-Smokers -Neutrophil predominant inflammation -African American children with poorly controlled asthma -We know that mild to moderate asthmatics do better on ICS than with alternatives -We also know that with increasing severity, increasing the dose of ICS alone is not enough

Question 28

ICS: SE

Answer 28

-Oral thrush: prevent with use of spacer and rinsing after use -Dysphonia: prevent with spacer, rest voice, decrease dose temporarily -Reflex cough/bronchospasm: prevent with slower inhalation or pretreat with SABA -Linear growth velocity: may slow linear growth velocity but uncontrolled asthma may also slow growth Studies show loss in height small, nonprogressive and may be reversible (??). -Bone mineral density: doses \>2000 mcg of beclomethasone a day and age \>18 years old Consider biphosphonates and monitoring bone density q 1–2 years if at high risk -High-dose inhaled corticosteroids Increased rate of bone fractures with COPD 9 of 15 -Disseminated varicella: if only with systemic steroids Prevention: vaccinate! -Thinning of skin/easy bruising -Ocular effects (cataract and glaucoma): no higher risk at low to medium dose -Higher risk if + fam hx of glaucoma, need regular eye c-checks -Hypothalamic-pituitary-adrenal axis function: clinically insignificant or no effect at low or medium dose (HPA Axis) Glucose metabolism: Not signifigant

Question 29

Age Groups

Answer 29

-0-4 -5-11 -12 and up

Question 30

Oral Steroids Long Term Use

Answer 30

-Only for the most severe cases -Mechanism: suppresses, controls, and reverses airway inflammation -Side effects closely related to dose, frequency of administration (QOD better than QD), duration of steroid use -Not used for Long Periods of Time -Better to take Every Other Day

Question 31

Oral Steroids: SE

Answer 31

-Eyes -Adrenal suppression -Growth suppression -Dermal thinning -Hypertension -Cushing's syndrome -Muscle weakness -Osteoporosis -Striae -Loss of delayed-type hypersensitivity -Decreased IgG -Increased risk for infection -Risk for reactivation of latent TB -Risk of severe varicella -Weight gain/increased appetite

Question 32

Cromolyn and Nedocriomil

Answer 32

-Not preferred but alternative treatment for asthma -Can be used for prophylaxis Mechanism: anti-inflammatory, Blockade of chloride channels, Modulate mast cell mediator release -QID dosing best, BID may work May protect against hospitalization, lacking data

Question 33

Cromolyn and Nedocriomil: SE

Answer 33

-Cromolyn: allergic reaction, uticaria, Eosinophillic Pneumonia, cough, wheezing, throat irritation, dry mouth, Angioedema -Nedocromil: liver problems, cough, bronchospasm, chest pain, dizziness, N?V, diarrhea, abd pain, dry mouth, bad taste, ALT Elevation, pneumonitis with eosinophilia

Question 34

Immunodilators

Answer 34

-Methotrexate -Interleukin-4 receptor -Anti IL-5 -Recombinant IL-12 -IVIG -Clarithromycin and Cyclosporin A, less popular -All "steroid sparing" and to help with long-term control (step 5 or 6 can use less) -Omalizumab (anti-IgE or Xolair) Xolair used most often (really good) -Steroid sparing (Step 5 and 6) (can use less)

Question 35

Omalizumab (Xolair)

Answer 35

-adjunctive therapy in Step 5 or 6 for severe persistent asthma -works on the IgE antibody -Approved for patients aged 12 and over known to have inhaled allergen sensitivities (skin test) -very expensive weekly injections -Adverse Effects: injection site pain, Bruising, Uticaria, Anaphylaxis, Risk of Malignancy (Small)

Question 36

Leukotriene Inhibitors

Answer 36

-Alternative but not preferred treatment for mild persistent asthma (2nd line) -Or adjunct to ICS (1st line) (12 and over use LABA first) -Montelukast (Singulair), Zafirlukast (Accolate), and Zileuton (Zyflo) -Check LFTS Regularly!

Question 37

Leukotriene SE

Answer 37

-can disrupt sleep (insomnia and weird dreams) -Singulair

Question 38

Leukotriene Modifiers

Answer 38

-5-lipoxygenase pathway inhibitors (Zileuton = Zyflo) -Approved age 12+ -Need to Check LFTs Regularly -Cytochrome P450 inhibitor -Side effects: Elevated Liver Enzymes, headache, nausea, dyspepsia, abd pain

Question 39

Long Acting Beta-Agonists

Answer 39

-Salmeterol (Serevent) and formoterol (Foradil) -Relax smooth muscle in airway by stimulating Beta-2 receptors, increasing cyclic AMP → antagonizes bronchoconstriction -Lipophilic: stays in lung tissue a long time → duration of action for 5–12 hours -Never use as monotherapy in asthma -May be used as montherapy in COPD -Black-box warning -Increase risk of life-threatening or fatal asthma exacerbations associated with regular use -adverse cardiac events -Risk highest in African Americans -Maintenance of lung function despite worsening obstruction → delay in care? -If a patient can not be controlled on an inhaled corticosteroid alone, step up to ICS-LABA -Teach, monitor appropriately.

Question 40

ICS + LABAs

Answer 40

-black box warning -adverse effects not present when used together -Asthma Treatment Step 3 or Higher -Therapy for Pts in C or D

Question 41

Methylxanthines

Answer 41

-Theophylline and SR Theophylline -alternitive but not preferred to treatment for MIld Persistent asthma -mild to moderate bronchodilation -caffeine (same family) similiar effects -medication of last resort (toxicty, interactions, and se) -Tachycardia,PVCs, N/V, Severe headache

Question 42

Phosphodiesterase 4 Inhibitoor

Answer 42

-COPD only, category C and D -Single Daily Dose, 24 Duration -Diarhea and weight loss common 1st 6 months (COPD pts already at risk for being underweight) -Contra: with Severe Hepatic Disease, Preg C, in Milk

Question 43

Leukotrine Receptor Antagonists LTRAs

Answer 43

-Montelukast (Singulair) -Can use in children 6 months and older. Cytochrome P450 substrate, Benefit of once-daily dosing -Zafirlukast (Accolate) -Can be used in children 5 years and older, Cytochrome P450 substrate and inhibitor, Requires BID dosing

Question 44

Singulair and Behavior

Answer 44

-mood/behavior changes -suicide

Question 45

ICS vs ICS + LABA

Answer 45

-If pt can be Controlled on ICS Alone, use ICSAlone -If not, step up to ICS + LABA

Question 46

Bad Breath

Answer 46

-Thrush -GERD (Most Common Diffferential)