Ex5 Asthma/COPD

Question 1

Bronchospasm is most likely to occur

Answer 1

at induction

Question 2

Severe asthma is defined as

Answer 2

1 major + 2 minor criteria

Question 3

Major criteria

Answer 3

tx w/ high-dose inhaled corticosteroids or tx w/ oral corticosteroids for 50%+ of the year

Question 4

Minor Criteria

Answer 4

-albuterol daily
-near fatal asthma event in past
-require addtnl daily controller tx (long acting beta agonist, theophylline, omalizumab, leuk recept antag)
-persistent airway obstruction (FEV1 <80%, peak exp <20%)
- >/= 1 urgent care visit/year
>/= 3 corticosteroid bursts/year

Question 5

Risk factors of mortality + asthma exacerbation

Answer 5

• prior episode of near fatal asthma
• in prior year: >/= 2 hospitalizations or >/=3 ED visits
• in past month: hospitalizations/ED visit for asthma or use >/=2 canisters short acting b-agonist
• social hx: major psychosocial issues, illicit rx use, low socioeconomic
• concominant illness: cv/mental/chronic lung dx

Question 6

Management of asthma exacerbation

Answer 6

• mechanical ventilation
• Rx: B-agonist, anticholinergic, corticosteroids, mag
• NonRx: o2, heliox

Question 7

First line Rx tx - asthma exacerbation

Answer 7

Beta agonists (rapid acting)

Question 8

Beta-2 agonists cause

Answer 8

bronchodilation of smooth muscle

Question 9

Selective Beta-Agonists

Answer 9

Albuterol
Levalbuterol
Terbutaline

Question 10

Non-selective Beta-receptor agonists

Answer 10

Epinephrine

*acts on both B1/B2 receptors

Question 11

Selective beta-agonists at high doses may lead to

Answer 11

loss of selectivity

–> tachycardia

Question 12

Onset - Beta agonists

Answer 12

5 minutes

Repeat until bronchospasm subsides

Question 13

After several hours of no response to tx with Albuterol in acute asthma exacerbation, what are next steps?

Answer 13

• Consider Terbutaline injection (SubQ) or Epi injection (SubQ/IM)
• c/i - arrythmia/HTN/CHF/CAD

Question 14

Beta-agonist AEs

Answer 14

• tachyphylaxis
• hypokalemia
• hyperglycemia
• Tybe B Lactic Acidosis

Question 15

Rx intxns: Beta-agonists

Answer 15

Other adrenergic Rx –> tachycardia

Beta blockers - some extent of antagonism

Question 16

Adverse effect of anticholinergic therapy

Answer 16

inhibits mucus secretion

Question 17

Add on to beta-agonists in asthmatics

Answer 17

anticholinergics (ipratropium)

Question 18

Role of corticosteroids in asthma exacerbation

Answer 18

Onset: 6-8h from administration; no significant role if given during acute exacerbation but should be started eventually for improved outcome postop

Question 19

oral vs. iv corticosteroids

Answer 19

same efficacy as long as absorption is not compromised

Question 20

Benefit of corticosteroids in asthmatic

Answer 20

Improves B2 receptor sensitivity to agonists

Question 21

Role of steroids in OR

Answer 21

IV or nothing. No role for inhaled steroids

Question 22

Which steroid would never be used for asthma/COPD?

Answer 22

Fludrocortisone

Question 23

Rx used when life-threatening exacerbation remains severe (peak exp flow <40% of baseline) after 1h of intensive therapy

Answer 23

• Magnesium Sulfate 2g over 20 min (may not help, won’t hurt)
• Ketamine

Question 24

Contraindication to Magnesium treatment in severe asthma exacerbation

Answer 24

Hypermagnesemia or renal failure(?)

norm mag = 1.3-2.4

Question 25

COPD Exacerbation Risk factors

Answer 25

``` Smoking Infections Previous hospitalizations Increased age multiple comorbidities Need for long term O2 therapy Severe COPD (stage 3/4) Outpatient use: systemic/inhaled steroids ```

Question 26

Key symptom of COPD

Answer 26

Dyspnea

Question 27

COPD exacerbation lasts for

Answer 27

7-10days

Question 28

Most common causes of COPD exacerbations

Answer 28

``` Respiratory infection (viral/bacterial) Air pollution Interruption of maintenance therapy ```

Question 29

COPD exacerbation tx

Answer 29

Beta-agonists = 1st line +cholinergic +steroid/antibx - no diff between MDI/neb - no role for long acting beta agonist during acute exacerbation

Question 30

COPD exacerbation: additional tx

Answer 30

Prednisone 40mg PO daily x 5 days * or equivalent dosing of hydrocort/methylprednisolone * may start with IV steroids and transition to oral

Question 31

When are antbx not used in COPD?

Answer 31

Pt arrives to OR - intubation triggers COPD exacerbation or an allergy

Question 32

When are antbx used in COPD?

Answer 32

Pt arrives with fevers, chills, cough potential PNA infxn

Question 33

Antibiotics chosen in COPD depend on

Answer 33

Hx of antbx use (do NOT use same antbx used w/in past 3 months)

Question 34

Most common pathogens in COPD exacerbation

Answer 34

Strep pneumoniae H.flu Moraxella catarrhalis Pseudomonas (COPD stages3/4)

Question 35

COPD antibiotics

Answer 35

Zosyn | Ceftriaxone+azithro+tobra

Question 36

Post op what MUST be done (COPD)?

Answer 36

Vaccination 1. annual influenzae vacc 2. Pneomococcal polysaccharide age < 65 3. Pneumococcal conjugate age 65+

Question 37

COPD exacerbation prevention

Answer 37

azithro or erythromycin PO

Question 38

Which drugs may trigger an exacerbation?

Answer 38

- Propofol with metabisulphites | * esp in heavy smokers

Question 39

Which drugs should be used in COPD/asthma pts?

Answer 39

- Inhaled anesthetics (bronchodilatory) * NOT desflurane - Ketamine

Question 40

What should be avoided during operation for asthma/COPD risk pts?

Answer 40

- avoid anxiety/pain - caution with instrumentation - caution for allergies - minimize risk of aspiration