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Flashcards in Midterm Deck (70):
1

Which of the following is the best food source of vitamin A (not beta-carotene)?

a. Eggs
b. Pumpkin
c. Kale
d. Barley

Eggs
*Preformed vitamin A is only found in animal source foods.
* Liver, because vitamin A is stored there, is by far the richest source
*Top US food sources are dairy, liver, fish, and fortified cereals

2

Which of the following has been associated with excessive vitamin A intake?

a. Pseudotumor cerebrii and cerebral edema
b. Follicular hyperkeratosis
c. Nail bed changes
d. Respiratory failure

Pseudotumor cerebrii and cerebral edema

3

Too much beta-carotene from the diet or supplements is associated with _______.

a. little risk of vitamin A toxicity symptoms
b. birth defects
c. headache
d. GI distress

little risk of vitamin A toxicity symptoms

4

Which of the following is accurate about steroid use for asthma?

a. nebulized steroids are only for use when disease cannot be controlled with long acting bronchodilators
b. nebulized steroids are best used as burst therapy to control disease flares
c. oral steroid burst therapy is generally for a single day at a dose about 50% of physiologic production
d. nebulized steroids are delivered bid to qid

Nebulized steroids are delivered bid to qid

5

Which of the following would NOT demonstrate substandard medication control of asthma?

Select one:
a. Uses SABA > 2x per week
b. Required oral steroids to control symptoms 3 months prior
c. FEV1/FVC ratio < 0.7
d. Wakes > 2x month with symptoms

FEV1/FVC ratio < 0.7

6

Which of the following would be a likely group of side effects from SABA use?

Select one:
a. GI upset, ulceration, diarrhea
b. hypotension, fainting, fatigue
c. hypomagnesemia, bone loss
d. anxiety, palpitations, headache

Anxiety, palpitations, headache

7

You might consider reducing asthma medication intensity after ________ of consistent good control.

Select one:
a. 2 to 6 weeks
b. 5 to 10 years
c. 1 to 2 years
d. 3 to 6 months

3 to 6 months

*If worsening sx, step up q 2-6 wks
*If improving, step down after 3-6 mos of good control

*All pts with asthma should have SABA (albuterol). Other meds guided by the algorithm.

8

Which of the following medication classes can be a first line therapy for persistent asthma symptoms, and can also help to control seasonal allergies?

Select one:
a. decongestants (e.g., Sudafed)
b. leukotriene receptor antagonists (e.g., Singulair)
c. antihistamines (e.g., benedryl)

leukotriene receptor antagonists (e.g., Singulair)

9

According to GOLD guidelines, we would choose to use prophylactic antimicrobials for COPD patients only in the following circumstance:

Select one:
a. none of the above
b. two or more episodes of pneumonia in past year
c. meets diagnostic criteria for chronic bronchitis
d. history of pulmonary embolus in past three months
e. over the age of 90

none of the above

10

All of the following medications or classes can be used as bronchodilators, EXCEPT:

Select one:
a. Opioid medications
b. Theophylline
c. Beta-2 agonists
d. Anti-cholinergics

Opioid medications

11

Which of the following is most accurate about medication prescribing for COPD?

Select one:
a. Short-acting bronchodilators are used in the earliest stages of disease
b. Generally speaking, we would use a nebulized steroid, and consider adding a long-acting bronchodilator if steroid alone is unable to manage symptoms
c. We should refer to pulmonary rehab as next step after steroids if disease control is substandard
d. The order of prescribing in the medication algorithm is oxygen -> theophylline -> steroid -> LABA

Short-acting bronchodilators are used in the earliest stages of disease

12

Which of the following is most true of theophylline?

Select one:
a. It is only associated with modest benefit in COPD
b. In terms of risk / benefit ratio, theophylline is a much better choice than LABA, so is more frequently used
c. It is an anticholingergic
d. It increases the risk of infection, as it is immunosuppressive

It is only associated with modest benefit in COPD

13

Potentially dangerous intervention at the top end of dose range.

Vitamin A is a potentially dangerous intervention at the top end of dose range. You’ll need to monitor safety.

14

What are 2 uses of vitamin A?

prevention of deficiency and supraphysiologic dosing, don’t confuse these two intents

15

Vitamin A + Antibiotics effect?

Concurrent use with tetracycline antibiotics is potentially contraindicated, because many of the adverse events caused by vitamin A seem to be more common during tetracycline treatment

16

Vitamin A + Statins?

Statin drugs may elevate serum retinol levels by altering liver function.

17

Vitamin A + Immune system?

Vitamin A may (Increase) reduce the suppression of immune function and wound healing caused by administration of glucocorticoids.

18

Major uses of vitamin A?

*Immune function-improve vaccine response and reduce mortality from infectious disease
*Retinitis pigmentosa- heritable degenerative condition
*Acne vulgaris
*Iron deficiency anemia-deficiency can worsen iron deficiency anemia, via down regulation of erythropoietin production in the kidney Probably limited to people with frank deficiency

19

Vitamin A toxicity

Symptoms include liver damage, pseudotumor cerebrii, fatigue, headache, muscle ache, dry skin

*Teratogenic->Doses above 10K/day potentially

*Increased osteoporosis risk- High intakes of vitamin A, either via supplements or diet, have been correlated

*Increased LDL and decreased HDL->Vitamin A supplements at 25K/day have been associated

20

Beta-Carotene sources

Sweet potato, spinach, carrots, and pumpkin pie all contain over 100% of the DV for vitamin A RAE.

More generally speaking, many fruits and vegetables are strong sources of beta-carotene

21

Beta-Carotene Dosing

15 mg of beta-carotene should be enough to prevent vitamin A deficiency is practically all individuals

This would be 1250 RAE, and higher than the DRI for each age and demographic group

1 Retinal Activity Equivalent (RAE) = 12 mcg of beta-carotene

22

Beta-carotene toxicity

You can turn orange, this is called carotemia.
Deficiency of beta-carotene does not exist

23

Asthma-Treat to target goals

*Peak flows > 80% of personal best
*Use of SABA < 2x/wk
*Wakes from sx < 2x/mo
*No more than one burst of oral steroids in past year

*** Regardless of your treatment strategy, failure to meet these goals is indicative of need for more aggressive treatment

24

Asthma-Short acting bronchodilators (SABA)

*Albuterol
*Stimulates beta-2 receptors, leading to bronchodilation
*Usually delivered by metered dose inhaler (MDI), but can also be given by nebulizer
*Half-life is 1.6 hrs
*Dose: 2 puffs of MDI (usu 180 mcg) q 4-6 hrs prn
*SE: anxiety, palpitations, headache, dry mouth

25

Asthma-Inhaled corticosteroids (ICS)

*ICS is mainstay of persistent asthma treatment
*Ex: beclomethasone, budesonide
*Usually delivered via MDI, often 2-4 doses / day
*Dose will vary by medication, but generally, start at the lowest dose and work upward as needed
*SE: sore throat, hoarse voice, thrush
*Need to use spacer to ensure that steroids are inhaled, not swallowed
--*Have pt rinse mouth after administration to prevent swallowing, tooth decay

26

Asthma-Oral steroids

*Used in acute exacerbations, and often at the beginning of a new course of treatment
*Burst tx: 20-30 mg bid x 3-10 days
*Long term: 7.5-60 mg qd or qod (should refer if req this level of tx). Qod dose is considered safer.
*SE: agitation, blood sugar elevation, weight gain, bone loss, immune suppression

27

Asthma-Long-acting bronchodilators (LABA)

*Example: salmeterol, 50 mcg bid
*Would never use for immediate sx relief
*Never use w/o concurrent steroid
*SE: tachycardia, tremor, hypokalemia, heart rhythm disturbance
*Several combo meds combine steroid and LABA tx

28

Asthma-Leukotriene receptor antagonists (LTRA)

*Example: montelukast (Singulair)
*Blocks effect of LTD4 in lungs
*Also used for seasonal allergies
*Adult dose 10 mg qd. No addt'l benefit from higher dose
*SE: GI upset, hypersensitivity, insomnia, possibly neuropsychiatric issues (anxiety, aggression, etc)

29

Asthma-Medication side effects

Steroids
*Inhaled corticosteroids shouldn't cause significant bone *loss at low to moderate doses
*Adrenal suppression (measure DHEA-S to assess)
*p.o. Steroids associated with many problems

LTRA
GI, headaches, allergy

LABA / SABA
Agitation, tachycardia

30

Pulse oximetry

*Differential absorption of red v infrared light allows calculation of oxy/deoxyhemoglobin ratio

*Pts w/ pulse ox levels below 90% may require oxygen therapy

31

Peak flow meter:

*Take the highest of the three readings (not average)
*Record high reading in asthma sx diary
*Your personal best ever reading is your baseline 100% reading. This reading should not be established by using albuterol or other bronchodilator prior to testing.

*A peak (expiratory) flow meter is a device that measures the maximal rate of flow on forced expiration.

*ALL patients with asthma should be prescribed a peak flow meter and instructed in its use

*Readings below 80% of maximal value are indicative of under-treatment

*Readings below 50% of maximal value represent a crisis, and need urgent treatment

*Note that there are charts available for avg values by gender and age, but that individual variation is great.

*Check and record at the same time daily, preferably once in am, once at night

32

Pulmonary function testing

*Spirometry measures the amount and rate of air a person breathes in order to diagnose illness or determine progress in treatment.

*Spirometry is a more sophisticated way to assess for obstructive or restrictive diseases

*Spirometry is the most commonly used formal pulmonary function diagnostic test

33

Spirometry terms:
1. FEV 25-75
2. FEV 1
3. FVC

1. Forced expiratory flow @ 25%-75% vital capacity
2. Force expiratory volume in 1 seconds
3. Force Vital capacity

34

Spirometry in the diagnosis of asthma

*FEV1 / FVC < 70% is best evidence for obstructive defect

*FVC reduced <80% (He says <70%-Restrictive dz)

*FEV1 < 80% of predicted value is suggestive of an obstructive defect

*FEV1 < 40% of predicted is indicative of severe defect

*Improvement in FEV1 of > 12% with bronchodilator is also suggestive of asthma

35

Spirometry is a diagnostic test relevant in the workup of?

Many pulmonary diseases

36

Restrictive ventilatory pattern:

-Due to conditions where lung volume is reduced - e.g., fibrosing alveolitis, scoliosis.

The FVC and FEV1 are reduced PROPORTIONATELY:

*FVC reduced <80% (He says <70%)
*FEV1 reduced
*FEV1/FVC normal

37

Obstructive ventilatory pattern:

-due to conditions in which airways are obstructed due to diffuse airways narrowing of any cause - eg, asthma, COPD, extensive bronchiectasis, cystic fibrosis, lung tumours.

The FVC and FEV1 are reduced DIS-PROPORTIONATELY:

*FVC normal or reduced
*FEV1 reduced <80%
*FEV1/FVC reduced <70%

38

What separates asthma from COPD?

Asthma's Reversibility of obstructive deficit

39

Asthma - definition

*Inflammation of the airways
*Obstruction is due to bronchiole swelling
*Hyper-reactivity
*Episodic
*In an exacerbation, lung symptoms => unstable, severe & persistent
*Exacerbations d/t infection, allergen exposure, occupational/environmental exposure

40

Asthma airway effects:

* Airway remodeling: progressive loss of lung fncn d/t poor dz control

1. Bronchospasm
2. Acute Inflammation:
(Environmental factors-> dendritic cells->B & T lymphocytes->TNF-a->Mast cells, Neutrophils, Eosinophils)

3. Persistent Inflammation & Remodeling:
(Initiation->Amplification->Propagation)
*Blood vessels, Mucus, fibroblasts->Smooth Mm,

Cycle:
Th2/Th1 cytokines (IL-13, TNF-alpha) to Pro-inflammatory mediators

41

Test Sporatic changes of Asthma with??

Methacholine challenge

42

Key events in pathophysiology:

Bronchoconstriction:

Bronchoconstriction: smooth muscle contraction
*IgE or non-IgE mechanisms (about half of asthma patients have important allergy contribution)

43

Key events in pathophysiology:

Airway edema:

Airway edema: due to chronic inflammation
*Also mucus hypersecretion, muscle hypertrophy

44

Key events in pathophysiology:

Airway hyperresponsiveness:

Airway hyperresponsiveness: exaggerated response to stimuli
*Result of inflmtn, neuro, anatomic changes
*Test w/ methacholine challenge

45

Key events in pathophysiology:

Airway remodeling:

Airway remodeling: progressive loss of lung fncn d/t poor dz control
*Likely irreversible (Asthma vs COPD)
*Early Asthma is reversible, late = COPD

46

Cytokine balance:

Factors favoring Th1 vs TH2

TH1-Protective immunity:
Older siblings, early exposure to daycare, tuberculosis, measles, hepatitis A nfx, rural environment.

TH2-allergic dz's (Asthma):
Widespread use of Antibiotics, Western lifestyle, Urban environment, Diet, Sensitization to house dust mites & cockroaches

47

Asthma stats:

*US prevalence is 6.7% of population
*The most common chronic condition in children
*Predictors of disease risk:
****Poverty, air quality, access to medical care

*If one parent has asthma, chance is 1 in 3 (33%) that child will (Allergic Phenotype)
*Both parents have asthma: Increase to 7 in 10 (70%)

48

In chronic and severe asthma where airway restriction may no longer be reversible, what to do?

In this situation, the text recommends retesting after 40 mg po corticosteroids x 10 days.

49

Asthma - diagnosis

Spirometry findings:

*Obstructive disease (FEV1:FVC < .7)
*Decrease in airflow in mid-expiration (FEF 25-75%)
*Increase in FEV1 of > 12% w/ 2-3 puffs of short-acting bronchodilator
*Positive methacholine challenge test

50

Asthma worse/critical criteria:
(Very Severe)

*Cough (Worse at night)
*GERD

51

Mild Intermittent:

*Attacks no more than twice a week.
*Nighttime Attacks no more than twice a month.
*Attacks last no more than a few hrs to days.
*No sx's b/t attacks.

52

Mild Persistent:

*Attacks more than twice a week (but not everyday).
*Nighttime sx's more than twice a month.
*Attacks severe enough to interrupt reg. activities.

53

Moderate Persistent:

*Daily attacks
*Nighttime sx's more than once a week
*More severe attacks at least twice a wk & may last for days
*Attacks req. use of quick relief (Rescue) medication
*Changes in daily activities

54

Severe Persistent:

*Frequent Attacks
*Continual daytime sx's
*Frequent nighttime sx's
*Sx's req. limit to daily activities.

55

Asthma Action Plan is assoc. with?

*Plan should be updated yearly
*Plan is associated with better dz control, less risk of complication

*This plan should be distributed to relevant places
School
Work
Camp

56

Urgent care Guidelines:

MILD:

FEV1 (>70%)-->Home
-Dyspnea only w/activity
*SABA (prompt relief)
*Short course Oral systemic Corticosteroids

57

Urgent care Guidelines:

MODERATE:

FEV1 (40-69%)-->Office
-Dyspnea interferes with or limits usual activity
*SABA (Frequent)
*Oral systemic Corticosteroids (Some sx's lasts 1-2 days after tx. begun)

58

Urgent care Guidelines:

SEVERE:

FEV1 (<40%)->ED visit or hospitalization
-Dyspnea at rest (interferes w/conversation)
*SABA (Partial relief, freq. inhaled)
*Oral systemic Corticosteroids (Some sx's lasts >3 days after tx begun)
*Adjunctive therapies are helpful

59

Urgent care Guidelines:

LIFE THREATENING:

FEV1 (<25%)->Req. hospitalization/ED
-Too dyspneic to speak (Perspiring)
*SABA (Minimal/no relief, freq. use)
*Intravenous Corticosteroids
*Adjunctive therapies are helpful

60

Asthma:
Patient in acute distress

(Bronchodilator) 1/2 life 1.6 hrs-> more can mask a more severe sx’s and can get bad when med wears out..)

1. Measure peak flow
*50-80%: use SABA
*< 50%: Immed. transport to ER

2. Give up to 2 tx w/ SABA (2-6 puffs) 20 mins apart
**Peak flow > 80%: continue SABA q 4-6 hrs, consider p.o. Steroids
**50-80%: continue SABA, add p.o. Steroids, monitor pulse ox
**< 50%: add p.o. Steroids, go to ER

61

Asthma:
Signs of emergent / life-threatening presentations

* Reduced wheezing (d/t reduced flow)->if they can’t breath but the wheezing goes down

*Pt should not leave office until >75% of peak flow target

*If you can control attack w/ beta-agonist in outpatient setting, monitor pt p tx x 1 hr

*Visible or paradoxical chest movement
*Speaks in words only (not sentences)
*Pulse > 120/min
*Pulsus paradoxus
*Cyanosis
*Peak flow < 50% (Or 100 L/min under predicted)
*FEV1 < 50%
*Pulse ox < 92%

62

Therapeutic diets for asthma

*Diet goal number one is to manage obesity effectively. Increased weight = increased intrathoracic pressure.

*Only about half of asthma patients have a significant contribution from IgE.

63

Therapeutic diets – sodium restriction

*The theory behind salt restriction is to thin mucus secretions, allowing for less airway restriction.

*Plant-based diet plus low sodium (2,300 g or less)

64

Therapeutic diet – food triggers

* 5% of asthmatics have food allergy/sensitivity (may approach 50% in poorly controlled pts)
* Sulfite-sensitivity affects about 5-10% of asthmatics

***Aspirin-sensitive asthmatics may also be triggered by dietary salicylates and additives like tartrazine

65

Nutrient therapies for asthma – magnesium

*Magnesium, 300-500 mg qd:
(For Asthma control- May take a long time to help->3 months for benefit)

*Both beta-agonist treatment and oral steroids may deplete magnesium stores. I.V. magnesium may decrease hospitalizations in children with severe acute asthma, especially in treatment resistant disease. Can also use inhaled magnesium sulfate.

66

Nutrients for asthma - antioxidants

1. Vitamin C, 1 gram per day: Reduces airway spasm, particularly in exercise-induced disease or related to air pollution.
**One successful intervention combined vitamin C with omega-3 fats and zinc

2. Natural-source beta-carotene, 64 mg / day
3. Lycopene, 30 mg qd

67

Exercise induced asthma- Antioxidants

1. Combine vitamin C with omega-3 fats and zinc
2. Natural-source beta-carotene, 64 mg / day
3. Lycopene, 30 mg qd

68

Asthma - Managing allergen exposure

*IgE is the key contributor here, so testing should look at IgE

*Inhaled allergens tend to be more contributory than foods to lower respiratory sx

*Pets, upholstered furniture, carpets are all common contributors

*Use high-quality air filtration system and clean filters regularly

*Cigarette smoke, wood burning are key pollution contributors

*Use hypoallergenic bedding as possible

69

Asthma - Dust mites

*Keep home < 50% humidity
*Remove carpets, curtains, upholstered furniture
*Damp mop regularly
*Wash bedding in hot water 1x/wk
*Wash stuffed toys wkly

70

Asthma Management & Tx.

Management:
*Monitor peak flows and SABA use
*See pt quarterly if good control
*Co-manage patients with poor control
*Peak flow < 50% activate EMS

Treatment:
*SABA is key conventional tx
*Control allergen exposure, air quality
*Use anti-inflammatory tx as possible
*Keep weight under control
*Match aggressiveness to sx control