Module 5: Respiratory (b)

Question 1

Asthma Management

-Step 1

Answer 1

1. PRN SABA
   AND
2. At the start of RTI: Add short course of daily ICS

Question 2

Asthma Management

-Step 2

Answer 2

1. Daily low-dose ICS & PRN SABA

Alternative:
-Daily Montelukast or Cromolyn & PRN SABA

Question 3

Asthma Management

-Step 3

Answer 3

1. Daily medium-dose ICS and PRN SABA

Question 4

Asthma Management

-Step 4

Answer 4

Daily medium dose ICS-LABA & PRN SABA

Alternative:
-Daily medium dose ICS + Montelukast & PRN SABA

Question 5

Asthma Management

-Step 5

Answer 5

1. Daily high-dose ICS-LABA & PRN SABA

Alternative:
-Daily high-dose ICS + Montelukast & PRN SABA

Question 6

Asthma Management

-Step 6

Answer 6

Daily high-dose ICS-LABA + oral systemic corticosteroid and PRN SABA

Alternative:
-Daily high-dose ICS + Montelukast + oral systemic corticosteroid & PRN SABA

Question 7

Classification of Asthma Severity

-Changes from 0-4 yrs to 5-11 years

Answer 7

Charts are identical for both age groups with one addition

-5-11 year olds have LUNG FUNCTION tests for FEV/FVC rations

Question 8

Classification of Asthma Control

->/= 12 years old Difference?

Answer 8

1. Can use a validated questionnaire

Question 9

COPD

-Definition

Answer 9

1. Chronic lung dz characterized by small airway obstruction and reduction in expiratory flow rate.
2. Spirometry required to make diagnosis
   - FEV/FVC <0.70 confirms airflow limitation

Question 10

COPD

-Goals of Therapy

Answer 10

1. Reduce Symptoms
   - Relieve symptoms
   - Improve exercise tolerance
   - Improve health status
2. Reduce Risk
   - Prevent Dz progression
   - Prevent/treat exacerbations
   - Reduce mortality

Question 11

COPD

-Pharm Therapy for Maintenance?

Answer 11

1. SABA’s and LABA’s
2. Anticholinergics/Antimuscarinics (short and long acting)
3. Phosphodiasterase-4 inhibitors
4. ICS

Question 12

COPD

-Pharm Therapy for Exacerbations?

Answer 12

1. Short-acting bronchodilators
2. Systemic corticosteroids
3. Antibiotics

Question 13

COPD

-LABA’s?

Answer 13

1. Salmeterol (Serevent)
   - 50mcg/actuation
   - Adults: 1 puff q12 hrs
2. Formoterol (Performist)
   - 20mcg/2 ml neb
   - Adults 20 mcg per neb q12 hr (max 40 mcg daily)

LABA monotherapy is okay with COPD but NOT with Asthma
-NOT for Pregnancy/Lactation

Question 14

COPD

-Antimuscarinic Antagonists?

Answer 14

1. MOA
   - Relax bronchial muscles causing Bronchodilation; decrease mucous production.
2. Contraindication/Caution
   - Allergies to atropine, soy, peanuts
   - Not for Acute Bronchospasm
   - Caution in narrow-angle glaucoma, BPH, pregnancy and lactation
3. A/E’s
   - restlessness, dizziness, HA, GI, blurred vision, cough, urinary obstruction

Question 15

COPD

-Short-Acting Antimuscarinics?

Answer 15

1. Ipratropium (Atrovent)
   - Available as neb or inhaler
   - Caution in pregnancy/lactation
2. Combivent (Ipratropium/Albuterol)
   -Caution in pregnancy/lactation
   —Albuterol can reduce uterine contractility**

Question 16

COPD

-Long-Acting Antimuscarinics

Answer 16

1. Tiotropium (Spiriva)
   - Delivery takes a lot of coordination d/t needing to put in and puncture med capsule
   - Not good for elderly with poor fine motor control**
2. Aclidinium (Tudorza)
   - Need to be able to take a BIG DEEP breath in. Click heard when med is delivered
3. Caution in pregnancy/lactation

Question 17

COPD

-Phosphodiesterase-4 Inhibitors (PDE4)

Answer 17

1. Roflumilast (Daliresp) 500mg pó daily
2. Indicated for SEVERE COPD associated with recurrent exacerbations
3. Contraindication/Caution
   - Hepatic impairment
   - Caution w/ depression, and SI
4. A/E’s
   - Diarrhea, nausea, weight loss, HA, back pain, dizziness, loss of appetite
5. Caution in pregnancy/lactation

Question 18

Assessment of COPD

-Grading?

Answer 18

GOLD 1 = FEV >/= 80
GOLD 2 = FEV 50-79
GOLD 3 = FEV 30-49
GOLD 4 = FEV = 30

Question 19

COPD

-How to classify?

Answer 19

1. Spirometry shows the Grade (GOLD 1-4)

2. Group is based on symptoms and exacerbations (Group A-D)

Question 20

COPD Treatment

-Group A

Answer 20

This patient is LESS symptoms and LOWER risk*

1. Short-acting antimuscarinic SAMA
2. Short acting beta agonist SABA

Question 21

COPD Treatment

-Group B

Answer 21

This patient is LOW Risk and MORE symptoms

1. LAMA or LABA
   - both with severe breathlessness **

Question 22

COPD Treatment

-Group C

Answer 22

This patient is LESS symptoms and MORE risk
-Pt has had >/= 2 exacerbations or been hospitalized

1. LAMA

Question 23

COPD Treatment

-Group D

Answer 23

1. LAMA
   Or
2. LAMA + LABA (For Highly symptomatic pt’s with CAT > 20
   Or
3. ICS + LABA (If eosinophil >300 or hx of asthma)

Question 24

COPD

-Pharm Mgmt Follow up

Answer 24

1. Review: symptoms (Dyspnea) and exacerbation risks
2. Assess: inhaler technique and adherence
3. Adjust: pharm treatment, including escalating or de-escalating

Question 25

Follow-up Pharm Management | -Persistent Dyspnea

Answer 25

1. Persistent Breathlessness or Exercise Limitation on Monotherapy? - Two Long-acting bronchodilators recommended 2. Persistent Breathlessness or Exercise Limitation on ICS/LABA? - Add a LAMA 3. If symptoms still progress, INVESTIGATE other causes

Question 26

Follow-up Pharm Management | -Exacerbations continuing?

Answer 26

1. Consider a LABA/LAMA or LABA/ICS combo if on mono-therapy - LABA/ICS for hx of asthma or Eosinophils >300 2. On LABA/LAMA - escalate to LABA/LAMA/ICS (with eosinophils >300) - Or add Roflumilast - Or azythromycin for (Former smokers) 3. On LABA/LAMA/ICS -Add Roflumilast Or -Azythromycin if former smoker

Question 27

COPD Exacerbations | -Presentation

Answer 27

1. Increased airway inflammation and increased mucous production 2. Symptoms: - Dyspnea - Increased sputum purulent and volume - Increased cough and wheeze

Question 28

COPD Exacerbations | -Classifications

Answer 28

1. Mild - Treated w/ Short-acting bronchodilators 2. Moderate - Treated w/ Short-acting bronchodilators + Antibiotics and/or oral corticosteroids 3. Severe - Requires hospitalization or ER visit - May be associated w/ Acute Respiratory Failure

Question 29

Management of COPD Exacerbations?

Answer 29

1. O2 if spo2 is = 88% 2. Bronchodilators: SABA + SAMA (DuoNeb) 3. Systemic Corticosteroids - Prednisone 40 mg daily x 5 days - Recommended for pt’s w/ exacerbations more than mild severity 4. Antibiotics - Increased dyspnea, volume of sputum or smoker hx - AUGMENTIN, Macrolides or tetracycline 5-7 day course

Question 30

Management of COPD Exacerbations? | -Antibiotics?

Answer 30

1. AUGMENTIN 2. Macrolides 3. Tetracycline 5-7 day course

Question 31

Acute Bronchitis | -State

Answer 31

1. 95% of acute bronchitis caused by viral infections 2. Evidence for cough suppressants is controversial 3. NO ANTIBIOTICS**

Question 32

CAP | -Stats

Answer 32

1. S. Pneumonia MOST COMMON pathogen | 2. Amoxicillin, doxycycline, fluoroquinolones are agents of choice

Question 33

CAP Treatment | -No Comorbidities w/ NO recent antibiotic use?

Answer 33

1. Amoxicillin 1 Tm TID x5-7 days | 2. Doxycycline 100 mg BID x 5-7 days

Question 34

CAP Treatment | -Co-morbidities or antibiotic use in past 3 months?

Answer 34

1. Levaquin 750 mg daily x5 days 2. AUGMENTIN BID or Cefpodaxime or Cefuroxime PLUS Azithromycin Or Clarithromycin 5-7 days

Question 35

CAP | -Children Under 5 yrs?

Answer 35

1. Bacterial Pneumonia - Amoxicillin - Azithromycin 2. Infant 4-16 wks w/ suspected chlamydial PNA -Azithromycin 3 days OR -Erythromycin 14 days

Question 36

TB | -First Line Drugs?

Answer 36

1. TB requires multi-drug regimen over 9 months. 2. Initiation phase is first 2 months followed by continuation phase for 4-7 months. Meds: - Isoniazid - rifampin - rifabutin - rifapentine - Pyrazinamide - Ethambuton

Question 37

TB | -Second line Drugs?

Answer 37

1. Cycloserine 2. Ethionaminde 3. Moxifloxacin 4. Gatifloxacin

Question 38

COVID-19 Referrals | -Monoclonal Antibody infusion/injection

Answer 38

1. Indicated for 12 years and older PLUS - Treatment in high-risk individuals - Prophylaxis in High-risk individuals 2. Give to individuals who are: - High risk + Not vaccinated or immune-compromised - No pre-exposure indication for treatment - NOT a substitute for vaccination

Question 39

COVID-19 | -Things to avoid in clinic?

Answer 39

1. Avoid nebulizer in clinic d/t spreading particles | 2. Avoid Spirometry w/ confirmed or suspected COVID 19