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IPCS 3 > Pulm Exam 2 > Flashcards

Pulm Exam 2 Flashcards

(107 cards)

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1
Q

What is the most common site of ADR

A

skin, GI, CNS

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2
Q

Common presentations of drug-induced pulmonary disorders

A

apnea
bronchospasm
pulmonary edema
pulmonary eosinophilia
pulmonary fibrosis

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3
Q

Risk factors for drug-induced pulmonary disorders

A

age
pre-existing lung disease
combo therapy
cumulative doses
oxygen therapy
radiation therapy
occupational risk factors

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4
Q

Diagnosis for drug-induced pulmonary disorders

A

nonspecific clinical, radiologic, and histologic findings
often at diagnosis of exclusion
characteristic pattern of reaction to a specific drug
discontinuing the drug may reverse toxicity

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5
Q

Classification of drug-induced pulmonary disorders

A

histology/pathophysiology
med class
clinical manifestation

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6
Q

meds that cause drug-induced bronchospasm

A

aspirin
beta-blockers
sulfites
contrast media
ACE
N-acetylcysteine
natural rubber/latex allergy

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7
Q

Airway obstruction/bronchospasm

A

most common drug-induced pulmonary disorders
increased risk in patients with pre-existing bronchial diseases

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8
Q

Pathophysiological mechanisms for airway obstruction/bronchospasm

A

anaphylaxis (PCN, ceph, sulfa)
direct airway irritation (N-acetylcysteine, pollutants, DPI)
beta 2 receptor blockade
cyclo-oxygenase inhibition (NSAID, ASA)
anaphylactoid mast cell degranulation (contrast dye)

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9
Q

Causes of apnea/respiratory depression

A

CNS depression
respiratory neuromuscular blockade

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10
Q

Risk factors for apnea/respiratory depression

A

Age
COPD
alveolar hypoventilation/CO2 retention
dose
multiple agents

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11
Q

ACE inhibitor induced cough

A

women > men
African Americans and Chinese
seen with all ACE-inhibitors
occurs 3 days to 1 year after initiation

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12
Q

Drug-induced pulmonary edema is a failure of any one, or combo of homeostatic mechanisms:

A

increase in capillary hydrostatic pressure due to left ventricular failure
disruptions in osmotic and oncotic pressures in vasculature
damaged alveolar epithelium
disruption in interstitial pulmonary pressure
obstructed interstitial lymph flow

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13
Q

Drug-induced pulmonary eosinophilia (symptoms of loeffler’s syndrome)

A

fever
productive cough
dyspnea
cyanosis
bilateral pulmonary infiltrates
eosinophilia in the blood

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14
Q

Drug-induced pulmonary fibrosis

A

chemo agents make up largest group
caused by:
O2 therapy
chemo
radiation
infection
inflammatory injury

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15
Q

Drug-induced pulmonary HTN

A

cocaine
oral contraceptives
amphetamines
chemo agents
anorexic agents

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16
Q

Drug-induced pleural effusions

A

methysergide, practolol (idiopathic)
drug induced lupus syndrome:
procainamide, hydralazine

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17
Q

Beta blocker induced bronchospasm

A

may increase risk of asthma
less risk in cardio-selective agents
caution with topical admin of timolol for open angle glaucoma

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18
Q

Sulfite-induced bronchospasm

A

rare, severe, life-threatening asthmatic rxn after restaurant meals and wines
-food preservative potassium metabisulfite
-could be EDTA and benzalkonium chloride

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19
Q

Management pre-treatment drugs for sulfite-induced bronchospasm

A

cromolyn
anticholinergics
cyanocobalamin

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20
Q

N-acetylcysteine

A

use via inhalation as a mucolytic
direct airway irritation
admin beta 2 agonist w/ or APAP prior to N-acetylcysteine

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21
Q

Drugs that cause drug-induced pulmonary edema

A

cardiogenic
excessive IV fluids
blood and plasma transfusions
corticosteroids
opioids
idiosyncratic rxn to med/high dose narcotics
salicylate overdose

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22
Q

Treatment for opioid-induced edema

A

naloxone, oxygen, ventilator
sx improve 24-48 h
CXR clear 2-5 days
pulm fx test abnormalities may persist up to 10-12 wks

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23
Q

Drugs that cause drug-induced pulmonary eosinophilia

A

nitrofurantoin
para-aminosalicylic acid
methotrexate
sulfonamides
tetracyclines
chlorpropamide
phenytoin
NSAID
imipramine

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24
Q

Drug-induced pulmonary eosinophilia treatment

A

rapid improvement in sx following disc
-complete recovery in 15 days of w/drawl
anecdotal reports steroids may be beneficial

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25
Signs and symptoms of drug-induced pulmonary fibrosis
dyspnea hypoxemia nonproductive cough diffuse alveolar damage interstitial pneumonitis
26
Risk factors for drug-induced pulmonary fibrosis: antineoplastics
cumulative dose increased age concurrent or previous radiotherapy oxygen therapy other cytotoxic drug therapy pre-existing pulmonary disease
27
Drug-induced pulmonary fibrosis: Belomycin
dose dependent generate superoxide anions sx: cough and dyspnea -chronic progressive fibrosis most common -acute hypersensitivity rxn occur infrequently
28
Other chemotherapeutic agents that cause drug-induced pulmonary fibrosis
alkylating agents antimetabolites methotrexate
29
Risk factors for drug-induced pulmonary fibrosis: amiodarone
from wk to 6 yrs before onset higher during first 12 months of therapy cardiopulmonary surgery combined with the administration of high concentrations of oxygen maintenance dose >400 mg for more than 2 months*** smaller doses for more than 2 years
30
Drug-induced pulmonary fibrosis amiodarone clinical features
exertional dyspnea (DOE) nonproductive cough wt loss occasional low grade fever radiographic changes are non-diagnostic hypoxia, restrictive changes and diffusion abnormalities
31
Management for drug-induced pulmonary fibrosis
disc therapy oxygen therapy maybe corticosteroids
32
Classification of pleural disease
pleurisy (caused by viral pneumonia) hemothorax, pneumothorax, chylothorax pleural effusion
33
Pleuisy (aka pleuritis) symptoms can be treated with what
NSAIDS cough suppressants
34
hemothorax, pneumothorax, chylothorax definition
a disruption in the pleural space and subsequent accumulation of air, blood, or lymph, resulting in compromised lung expansion
35
What is a tension pneumothorax
acute rapidly expanding pneumothorax; pressure exerted on the heart and greater vessels cause hemodynamic instability; may be fatal
36
Clinical presentation of hemothorax, pneumothorax, chylothorax
SOB DOE chest pain and dyspnea tachypnea cough
37
Management of hemothorax, pneumothorax, chylothorax
medical/surgical -chest tube thoracostomy adjunctive pharmacotherapy -analgesia (opioides 1st line agent) antimicrobial therapy
38
Antimicrobial therapy for management of hemothorax, pneumothorax, chylothorax
depend on circumstances of placement (use when placed in field) 1st gen cephalosporin (cedazolin x24 h)
39
Pathophysiology of pleural effusions
fluid movement into/out of pleural space determined by pressure gradient (hydrostatic pressure from vessels, oncotic pressure from proteins in blood plasma) "Fluid in" "Fluid out" Fluid accumulation due to loss of fluid homeostasis defines a pleural effusion
40
Pleural effusions: what does fluid in vs fluid out caused by
in: parietal pleura capillary hydrostatic pressure out: lymphatic drainage
41
What is transudative pleural effusion
increased hydrostatic pressure, decreased oncotic pressure or both pleural membrane not affected (pleurae are normal) management: treat underlying cause unresolved, severe, and recurrent effusions: thoracentesis, pleurodesis
42
What is exudative pleural effusion
result of pleural membrane disease (caused by pneumonia or neoplastic disease) management: treat underlying cause requires direct intervention
43
What is pneumonia and neoplastic disease as a result of pleural membrane disease
pneumonia: parapneumonic effusion neoplastic disease: lung, breast, lymph
44
Transudative: pleural fluid composition, pleural membrane involvement, most common etiology, often frequent cause
pleural fluid composition: low protein pleural membrane involvement: no most common etiology: HF often frequent cause: cirrhosis, PE, nephrotic sydrome, SVC obstruction
45
Exudative: pleural fluid composition, pleural membrane involvement, most common etiology, often frequent cause
pleural fluid composition: high protein, cell count, LDH pleural membrane involvement: Yes most common etiology: pneumoniae often frequent cause: neoplastic disease, infection (empyema), PE, drugs
46
Drugs that cause exudative pleural effusion
methotrexate bromocriptine nitrofurantoin dantrolene amiodarone
47
Diagnosis of pleural effusion
usually CXR (does not differentiate btw transudative and exudative)
48
Who gets treated in pleural effusions
symptomatic recurrent
49
General approach to management of pleural effusions
stabilize the patient (ABC) treat the underlying cause provide symptomatic relief prevent complications prevent recurrence
50
Management of pleural effusions: thoracentesis (pleuracentesis)
needle drainage one-time procedure effective, but high incidence of recurrence often diagnostic, not therapeutic
51
Management of pleural effusions: tube thoracostomy
drainage instillation of pharm agents tx of loculated effusions (intrapleural meds)
52
tx of loculated effusions in tube thoracostomy
streptokinase 250,000 units/urokinase 100,000 (units in 50-100 ml NS instilled once or twice daily) alteplase 10 mg in NS 50 ml BID x6 doses dornase alfa 5 mg in NS 50 ml BID x6 doses alteplase + dornase alfa
53
Management of pleural effusions: pleurectomy
radical, side effects, rarely used
54
Management of pleural effusions: pleuroperitoneal shunt
impractical/inconvenient, complicated, rarely used
55
What is chemical pleurodesis
admin of a sclerosing agent into pleural space to induce a chemical pleuritis, which will form symphyses
56
Chemical pleurodesis: candidates
symptomatic, recurrent effusions symptomatic improvement (decrease SOB) w/ complete lung re-expansion following thoracentesis no intrabronical obstruction
57
Chemical pleurodesis: administration needs to have the following
ability of lung to expand complete drainage of accumulated fluid complete distribution of agent absence of loculations
58
Chemical pleurodesis: agents commonly used
doxycycline (500-1000 mg x1-3 doses; repeat 2-3 d prn) talc (must be sterile, asbestos-free, larger particle; thprascopic insufflation vs slurry via chest tube) bleomycin (chemo agent)
59
Chemical pleurodesis: lidocaine
adjunctive therapy for local anesthesia 15-25 ml of a 1% soln (OR 3-4 mg/kg) instilled 15 min before procedure
60
What kind of channel is CFTR
cAMP activated anion (Cl-) channel it increased volume of secretions and decreased viscosity of lung mucus
61
What are the 6 different CFTR mutations
1: no protein 2: no traffic 3: no function 4: less function 5: less protein 6: less stable
62
What CFTR modulators are potentiators
ivacaftor deutivacaftor
63
What CFTR modulators are correctors
lumacaftor tezacaftor elexacaftor vanzacaftor
64
Potentiators do what
increase opening time of the CTFR channel resulting in higher ion flow
65
Correctors do what
facilitate the processing of mutated CFTR protein substrate leading to improved delivery to the cell membrane
66
Amplifers do what
selectively increase the amount of immature CFTR protein in the cell providing additional substrate for correctors and potentiators to act upon
67
Ivacaftor MOA
improve function of defective CFTR that reaches the cell surface binds to defective protein at cell surface and opens chloride channel improve gating capacity of CFTR activation of chloride channel of CFTR
68
Lumacaftor MOA
correct the processing and trafficking of defected CFTR CFTR can reach the cell surface at cell surface, the drug can further enhance the channel function
69
What drug causes chest discomfort and can increase bronchial secretions and productive cough
Orkambi Trikafta (only does increase secretions)
70
What drug causes cataracts and can increase serum bilirubin and transaminases
Alyftrek Trikafta (only does increase serum)
71
What is dornase alfa and its side effects
mucolytic agent chest pain, voice disorder, pharyngitis, rhinitis, skin rash
72
Dornase Alfa MOA
rhDNase which hydrolyzes the DNA in mucus of CF patients which decreases mucus viscosity
73
In CF, impaired anion transport results in decreased secretion of more acidic fluid leading to what
precipitation of secreted proteins which decreases action of digestive enzyme causing malabsorption intraluminal obstruction of ducts leads to progressive pancreatic damage and atrophy
74
Pancreatic enzyme replacement therapy (pancrelipase)
Creon, pancreaza, pertyze, ultresa, viokace, zenpep acts on GI tract contain combo of lipase, amylase and proteases natural product from porcine pancreatic glands causes neck pain, ad pain, nasal congestion
75
What are the organs effected by CF
lungs, digestive system, reproductive organs
76
What is the most common mutation of CF
delta F508 autosomal recessive disease
77
Pathophysiology of gene mutations CF
mucosal obstruction chloride transport expression of other gene proteins involved in inflammatory processes, ion transport, cell signaling
78
Pathophysiology of sweat glands CF
CTFR regulates ion transport and salt homeostasis chloride fails to be reabsorbed which impacts sodium ion reabsorption results in sweat with high salt
79
Pathophysiology of lungs CF
abnormal Cl conductance on apical membrane, decrease airway surface liquid cause ciliary collapse and decreased mucociliary transport causes mucus obstruction, infection, inflammation
80
Sinus and pulmonary clinical presentation of CF
chronic infection and nasal polyps in sinus cavity SOB/cough w/ sputum production flat chest, decreased FEV1 bacterial overgrowth
81
GI system clinical presentation of CF
obstruction of pancreatic ducts and intestinal tract, can not digest essential nutrients infants: meconium ileus, steatorrhea, fail to thrive older pt: severe constipation and insulin deficiency
82
reproductive system clinical presentation CF
male: blockage of or congenital bilateral absence of vas defs -> azoospermia females: decrease water content in cervics which decrease fertility
83
Diagnosis of CF
IRT QPIT (sweat chloride test) <29 normal, 30-59 intermediate, >60 diagnostic (collect test from second site to confirm)
84
Non pharm tx for CF
want normal wt in adults and normal growth in kids 110-200% energy intake (eat more food)
85
What vitamins to take with PERT
A, D, E, K (fat soluble) 30 or greater ng/mL
86
Dosing for PERT
500-2000 lipase units/kg/meal 10,000 lipase units/kg/day 4,000 lipase units/gm of dietary fat/day risk: <12 yo, doses >6,000 lipase units/kg/meal for >6 months, h/o meconium ileus, intestinal surgery, ibd
87
Formulations for PERT
capsules (can be mixed with food, do not let sit) Do not crush tablets can take with H2-antagonist or PPI
88
Risk factors for bone health and vitamin supplementation
malabsorption of vit D poor nutritional status physical inactivity glucocorticoid therapy antibiotics that require protection from sunlight exposure
89
DXA t/z score: >-1.0, >-2.0, <-2.0
>-1.0: repeat in 5 years (opt vit D, ca, vit K) >-2.0: repeat 2-4 years (improve nutrition, aggressive pulmonary tx, min steroid dosing, treat Cf-related diabetes) <-2.0: repeat yearly (improve nutrition, consider bisphosphonate)
90
ACT airway clearance therapy steps
bronchodilator hypertonic saline dornase alfa chest percussion aerosolized antibiotics
91
What are the 2 types of anti-inflammatory therapy for CF
Ibu (20-30 mg/kg BID) for 6-17 yo and FEV >60% Azithromycin (for pseudomonas)
92
Indications for antibiotic therapy for CF
acute pulmonary exacerbation, chronically infected w/ pasudomonas, require prevention of chronic psedudomonas use aerosolized antibiotics
93
Pathogens for CF
early: staph late: psedudomonas (need drug for cell wall destruction and inhibit cell wall synthesis) pathogens never fully eradicated
94
What to use for CF pt with stenotrophomonas
SMZ-TMP doxycycline
95
Vaccinations for CF pts
flu shot >6 months PCV COVID-19
96
Counseling for females and males with CF
female: OCP safe, DDI with OCP and antibiotics, patches may not adhere to skin male: not infertile
97
CFRD (cystic fibrosis related diabetes) clinical features
18-21 years females predominance yearly beginning at age 10 with OGTT insulin is therapy of choice
98
Ivacaftor indication and approved age
class 3, >1 month
99
lumacaftor/ivacaftor indication and approved age
delta F508 mutation, >1 year
100
tezacaftor/ivacaftor indication and approved age
delta F508 mutation, >6 year
101
elexacaftor/tezacaftor/ivacaftor indication and approved age
at least 1 delta F508 mutation, >2 years
102
vanzacaftor/tezacaftor/deutivacaftor indication and approved age
at least 1 delta F508 mutation or another responsive mutation in CFTR gene, >6 years
103
Pregnancy CF
high risk monitor levels in first trimester to avoid toxicity while cont A, D, E, K vitamins need more calories for breast feeding complications: increased o2 uptake, blood volume, cardiac output, may cause right sided-HF
104
Peds CF
education of pt and child
105
Transplant CF
those for severe disease <30% others: nutritional status, diabetes, number of CF exacerbations, compliance to care or immunosuppressant therapy
106
follow up for CF
q1-3 months
107
Desired outcomes in CF patients
sinopulmonary (prevent exacerbations, clearance of airways, bacterial colonization) GI (optimize growth and nutrition, calorie intake) psychosocial (education)

IPCS 3 (10 decks)

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