Asthma/COPD Flashcards

Question

Making the Dx of asthma

Answer 1

* Recurrent sx * Risk factors known * Response to drug (bronchodilator or steroids) * Other etiologies ruled out

Answer 2

* Prevent chronic asthma sx and exacerbations in day and nigh * Maintain normal activity; no limitations * Have normal/near-normal lung fxn * Prevent acute episodes * Reduce ED visits and hospitalizations * Have minimal SE on tx * Enhanced adherance (simple meds)

Answer 3

* Gain control * Maintain control

Answer 4

* Preferred approach is to start therapy with more intensive program * Suppresses airway inflammation and gain prompt control of reversible obstruction * Ex: burst therapy steroids * To do this, you need to define the severity of asthma * Intervene with optimal medications * Normalize activities, lung function and lifestyles * Then try to “step down” tx to optimal levels

Answer 5

* f/u q 1-6 mos (usually q3-4) * PFTs \>=2x/yr * “step down” long term control meds to achieve optimal control as safely and effectively as possible * Keep it- Simple, Safe, Effective

Answer 6

* No matter what **ICS is ALWAYS in the treatment regime for persistent asthma** * Pts are candidates of Mainstay Therapy if the “RULES OF TWO” apply * They are using a quick-relief inhaler \>2x/wk * They awaken d/t asthma \>2x/month * They refill their quick-relief inhaler Rx \>2x/year

Answer 7

* **Acute Tx or “Rescue” Therapies** * **Chronic “controller” therapies**

Answer 8

* Inhaled short acting β₂ agonists (SABA) (Albuterol, Xopenex®) * Systemic (injected) β₂ agonists (epinephrine, terbutaline) * Anticholinergics (Ipratropium bromide – Atrovent) * Systemic steroids (Prednisone; PO preferred) * 100% bioavailable; drug goes everywhere (not just lungs!) * Oxygen, hospitalization, ventilation

Answer 9

* Inhaled corticosteroids (***Flovent***®, ***Pumicort©***, ***Qvar®, Asthmanex®***) * Only about 2% is absorbed systemically (most goes directly to lungs) * Long-acting bronchodilators (LABA) (***Serevent***®, **Foradil**®) * **NEVER use as monotherapy!** * Mast cell stabilizers (***Intal***®): not used often * Leukotriene modifiers (***Singulair***®): good add-on therapy * Combination therapies (***Advair***®, ***Symbicort®, Dulera®***)

Answer 10

* **Long-term controller** asthma meds are taken daily to achieve and maintain control of **persistent asthma sx** * **Most effective long-term maintenance meds** **reduce inflammation**! * Inhaled steroids are best for persistent asthmatics * **ICS = First-line maintenance therapy for ALL persistent asthma, even mild** * Other classes of controller drugs, such as the **LTM’s** can be used, but they have limitations!

Answer 11

* ICS can decrease airway inflammation and bronchoconstriction of smooth muscle in mild to moderate asthmatics. * Earlier tx with ICS appears to prevent pts from developing more prominent chronic lung changes and airway obstruction * Long term use (\> 2 yrs) significantly improves lung fxn * Safe to use

Answer 12

* Diminish asthma sx; improvement will continue gradually * decreases occurrence of severe exacerbations * decreases use of quick-relief meds * Improved lung fxn (PEF, FEV₁, & airway hyperresponsiveness)

Answer 13

* Inhibits inflammatory mediator cells (decreases airway edema) * Can reverse effects of airway remodeling

Answer 14

* Safe and effective, easy to use, quick onset of action, well-tolerated * Enhance benefits of ICS & more effective than ↑ ICS * Treats nocturnal cough & exercise-induced bronchoconstriction for up to 12-14 hrs after use * Enhance adherence and improve lung fxn * **NOT TO BE USED AS MONOTHERAPY!**

Answer 15

* **Serevent^®** and **Flovent^®** are available together in a DPI (Diskus**^®**) as **Advair^®**(100/50, 250/50, 500/50) * Clinical efficacy of a LABA & ICS is due to complementary actions of these two classes of drugs * Treats BOTH inflammation and bronchoconstriction in a single device = IDEAL Leukotriene Modifiers (LTM) * Class of agents used in asthma therpay BUT limited long-term data exists * Best used as add-on therapy, esp. for stuffiness and persistent cough * Easy to dose, lack of perceived “steroid side effects” Play a role in initial asthma tx, however, only a fraction of people treated with these agents appear to respond to therapy and they tend to have milder and more intermittent disease

Answer 16

* Overall, **short-acting bronchodilators** account for over 50% of all asthma Rx among children and adults. * Despite that **asthma** is now recognized as a **chronic** **inflammatory** **disorder** * In Georgia, **less than half** of all asthmatics who need daily “controller” meds actually have them prescribed.

Answer 17

* Improvement in lung fxn tests or PFT’s (spirometry: FEV1 **\>** **6%** or FEF25-75 **\>** **35%**) * Improved AM/PM Peak Expiratory Flow * Using **Peak Flow Meters** (measure speed & amt of air expelled in single puff) * decrease use of “rescue” drugs (200 puffs per canister) * Shouldn’t be using more than 4 canisters annually! * decrease daytime and exercise-related resp. sx * decrease nocturnal awakenings/cough * Improved “quality of life”

Answer 18

* MDI’s are mainstay for most asthma controller meds prescribed in US * Small, portable, efficient, quick, & inexpensive to use (and lose!) * When used with a spacer device, MDI’s deposit particles in small airways as effectively as nebs * Effectively used at any age * Technique is CRITICAL! Require SLOW INSPIRATORY flow rates

Answer 19

* Asthma spacers * Dry Powder Inhalers (DPI’s) * Diskus

Answer 20

* Improved ease of use * Impact of impending CFC phase-out * decrease volume of inhaled powder * Dose counters/indicators * ↑ dose capacity in devices * No dose to dose variation

Answer 21

* Open: Expose level underneath device * Click: Push lever away until you hear or feel a click * Inhale: Exhale, then bring device to lips and breathe in steadily & deeply thru inhaler. Airflow thru device ensures that dose is inhaled * Close Diskus

Answer 22

* Have I visited the ER or hospital in past year? * Do I use my rescue-inhaler more than 2x/wk? * Have I found myself coughing or breathless in AMs and/or PMs? * Do I limit my activities or miss work/school? * Have I received Rx for oral prednisone \>1x in past year?

Answer 23

* Chronic Obstructive Lung Disease * Progressive airway obstruction * Associated with smoking 90% of COPDers have smoked * Not reversible * Combination of chronic bronchitis, small airway obstruction and emphysema

Answer 24

* Cigarette smoke (centrilobar emphysema) * Alpha-1- antitrypsin deficiency (panacinar emphysema) * Recurrent Airway infections

Answer 25

* Approx 5% of Americans have COPD for a total of ≈12 million * 125k deaths from COPD in ‘97

Answer 26

* Straw experiment * How does it feel to take so long to breathe out? * Shortness of breath, especially with exertion, resulting from being unable to expire completely…worsening over time * This is worsened with exercise/exertion because patients are breathing faster * Chronic, productive (especially in the morning) cough (can be a dry cough) * Wheezing…patients will tell you this * Chest tightness/heaviness * Recurrent acute bronchitis * Air hunger/increased effort to breathe * Symptoms can happen late; after 50% of lung function is lost

Answer 27

* Hypoxemia * Tachypnea * Dyspnea on exertion * Barrel chest/increased AP diameter * Air trapping, widened rib spaces on CXR * Wheezing (worse in exacerbation) * Nail clubbing * Peripheral edema (often later stage)- RHF * Hypercapnea (later stage)

Answer 28

* Normal lung function (FEV1) declines by 30 ml per year after the age of 30 * In COPD- declines by 100ml per year

Answer 29

* Smoking * Air pollution * Occupational exposure * Allergies * Hereditary/Genetics

Answer 30

* FEV1, BMI, Dyspnea, 6 minute walk (6MW) used as prognostic factors * FEV1 = 1 Liter is 4 year prognosis * End Stage COPD is approx. 1 year survival * Oxygen * Medicines

Answer 31

* Combination of Chronic Bronchitis and Emphysema * Narrowing of airway lumens and thickened walls

Answer 32

* Clinical diagnosis * Chronic cough and sputum production for at least 3 months of the year for at least 2 years. * In the absence of any other disease. * Caused by hypertrophy and hyperplasia of mucus secreting glands * Intermittent dyspnea, copious sputum

Answer 33

* Morphologic Diagnosis * Enlargement of airspaces distal to the conducting airways * Bronchioles and alveoli walls are weakened * Lysis of elastin and structural proteins * Types * Centrilobular- from smoking * Panacinar- alpha 1 def

Answer 34

* Involves the Bronchioles * With normal distal alveoli (except in severe dz) * Exclusively found in smokers * Central airway obstruction * Upper lobe predominant * Lung volume reduction surgery

Answer 35

* Alpha-1 antitrypsin deficiency * Genetic disease * Patients have severe disease when compared to age/pack history * Exacerbated by smoking * Lower Lobe predominant

Answer 36

* Onset \> age 50 * Dyspnea progressive, severe, constant * Cough and sputum production mild, absent * Weight loss * Body habitus is thin, cachexia * AP diameter increased/ barrel chest * Percussion hyperresonant * Auscultation diminished * CXR- bulla, blebs, hyperinflation, hemidiaphragms are flattened * Labs: EKG normal, ABG without hypercapnia or hypoxemia * PFTs: increased TLC, increased RV, decreased diffusion capacity

Answer 37

* Onset = after age 35 * Dyspnea is intermittent, mild to moderate * Cough and sputum production persistent and severe * No weight loss, can be obese, s/sx of RHF * No increase in AP diameter * Percussion normal * Auscultation = wheezing, rhonchi * PFTS: normal DLCO and RV/TLC * CXR = Cardiomegaly, increased lung markings * Labs – EKG with Rt Ventricular Hypertrophy, rt. Axis deviation * Hypoxemia and hypercapnia are moderate to severe, resp acidosis

Answer 38

* CHF * Chronic asthma * Pulmonary embolism * Bronchial asthma * Bronchiectasis * Cystic Fibrosis * Central Airway obstruction * Pulmonary Fibrosis

Answer 39

* Stage 0: At Risk * Stage I: Mild * Stage II: Moderate * Stage III: Severe * Stage IV: Very Severe

Answer 40

Stage 0: At Risk * Chronic s/sx * Exposure to risk factors * Normal PFTs * Treatment- influenza vac, avoid risk factors

Answer 41

* Stage I: Mild * FEV1/FVC \< 70% * FEV1 \>/= 80% * With or without s/sx * Treatment: * Avoid risk factors * Influenza vac. * SABA prn

Answer 42

* Stage II: Moderate * FEV1/FVC \< 70% * FEV1 btw 80 -50% * With or without s/sx * Treatment: * Avoid risk factors, influenza vac. * SABA prn * Long acting Bronchodilator Pulmonary Rehab

Answer 43

* Stage III: Severe * FEV1/FVC \< 70% * FEV1 btw. 50- 30 % * With or without s/sx * Treatment: * Avoid risk factors, influenza vac. * SABA prn * Long acting bronchodilator * Pulmonary rehab * ICS – if repeated exacerbations * Evaluate for oxygen * Daliresp (Roflumilast)

Answer 44

* Stage IV: Very Severe * FEV1/FVC \< 70% * FEV1\< 30% or \<50% with chronic respiratory failure * Treatment: * Avoid risk factors, influenza vac. * SABA * Long acting Bronchodilator * Pulmonary rehab * ICS * O2 * ? Surgical candidate for lung volume reduction surgery. * Consider hospice

Answer 45

* SABA * Albuterol * ProAir, Proventil 1-2 puff q4h prn * Levalbuterol * Xopenex 2 puffs TID prn * Long Acting Bronchodilators * Tiotropium (spiriva) * 1 puff qd * Iprotropium bromide * neb solu q6-8 h * LABA: Salmeterol or formoterol * use BID * Theophylline * ICS * Beclomethasone * Budesonide * Fluticasone * Combination Inhalers * Advair * Symbicort * Dulera * Oral Corticosteroids

Answer 46

* Complete PFT’s with ABG * 6MW * CXR - ? CT scan of Chest * Alpha one antitrypsin level * EKG * ABG – resp. acidosis * CBC * BNP B-Type Natriuretic Peptide * Echo

Answer 47

* decrease in FEV1, FVC, ratio

Answer 48

* increase in RV, TLC

Answer 49

* decrease in DLCO

Answer 50

* decrease PaO2, increase in PaCO2

Answer 51

* **Methylxanthines** * **Theophylline** * narrow therapeutic window * Cardiac sequelae if toxicities * Sometimes works, sometimes doesn’t * PO Albuterol is not safe from a cardiac standpoint (many COPD patients have concomitant cardiac disease) * Watch out for pneumothorax due to bullae; do a CXR with unexplained worsening dyspnea * In a young patient (age 40 or less) with COPD and a minimal or no smoking history, check an alpha-1 antitrypsin level…looking for a low level, indicating deficiency. * This is a genetic cause of COPD * Much higher incidence of COPD in HIV patients * Discuss code status with all COPD patients…IN THE OFFICE

Answer 52

* From patient’s baseline: * Change in sputum color * Increase in shortness of breath * Increase in amount of sputum * Also look for signs of infection: * Fever, chills, hemoptysis, crackles/rales on lung exam

Answer 53

* CXR to rule out pneumonia as a cause for the exacerbation * Check oxygen saturation! * Decide whether or not to treat as an outpatient: * PO steroids (prednisone)/bronchodilators * PO Antibiotics * Close follow up

Answer 54

* Hospitalized (hypoxemic, very dyspneic, fever, weakness) * IV steroids, usually methylprednisolone, starting at 60mg IV Q6 hours, and taper…try not to dose less than Q8 hours for duration due to drug ½ life (transition to prednisone for discharge) * Scheduled nebs; if on tiotropium (anticholinergic) do NOT use ipratropium * When giving oxygen give only enough to get PaO₂ above 60mmHg; this minimizes the danger of respiratory acidosis due to CO₂ retention. * Levalbuterol (q6 hours) or albuterol (q4 hours) nebs * Mucolytic (guaifenesin) prn * Sputum cultures, usually give antibiotics, covering for *S. pneumo, H. flu, M. cat.* * Quinolones, cephalosporins, penicillins, macrolides

Answer 55

* Nicotine replacement * Behavioral modification * Bupropion (Zyban, Wellbutrin) * Varenicline (Chantix)

Answer 56

* Patients need you to initiate the conversation…EVERY VISIT * Medicare now reimburses for smoking cessation counseling * If you don’t attempt it, you are not doing your job * Bring them back for a smoking cessation visit

Answer 57

* C: Corticosteroids (inhaled) * 20% decrease in Acute exacerbations, but can increase risk of pneumonia * O: Oxygen * P: Prevention (Flu/Pneumovax, tob cessation) * D: Dilators (Anticholinergic, SABA, LABA) * E: Experimental (LVRS = lung volume reduction surgery) * R: Rehabilitation

Asthma/COPD Flashcards

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