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NAPLEX BABY > Pulmonary Conditions & Tobacco Cessation > Flashcards

Pulmonary Conditions & Tobacco Cessation Flashcards

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1
Q

What is pulmonary arterial htn?

A

-high BP in pulmonary artery (mPAP > 25)
-diagnosed with a right heart catheterization
–> imbalance of vasoconstrictor/vasodilators, imbalance of proliferation/apoptosis = enlarged right ventricle and right heart failure
Symptoms: fatigue, dyspnea, chest apin, syncope, edema, raynaud’s phenomenon

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2
Q

drugs that can cause PAH?

A

-cocaine and methamphetamines
-fenfluramine
-SSRI use during pregnancy (can inc risk of persistent pulmonary htn of a newborn)
-weight loss drugs (phentermine, diethylpropion, phendimetrazine)

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3
Q

Treatment of PAH

A

Non-drug: sodium restriction and immunizations
Drug:
-start: warfarin (INR 1.5-2.5) +/- diuretics +/- oxygen +/- Digoxin –> right heart cath and acute vasoactive testing =
+ : oral CCB (not verapamil)
- : begin a PAH approved drug
—> PDE-5 inhibitor
–> endothelin receptor antagonist
–> soluble guanylate cyclase stimulator
–> prostacyclin analogue

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4
Q

Prostacyclin analogues & receptor agonists for PAH

A

–> potent vasodilators (pulmonary and systemic) and platelet inhibitors
- Epoprostenol (Flolan) - ~ 5 min 1/2 life, PROTECT FROM LIGHT, ice pack for stability
- Trepostinil
- IIoprost (Ventavisa)
-Selexipag (Uptravi)

SEs: vasodilatroy, GI, anxiety, chest pain/palps, edema, jaw pain, neuropathy, site pain w. SC treprostiril, cought w/ inhaled products

**life-threatening is stopped suddenly!

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5
Q

Endothelin Receptor Antagonists (ERAs) for PAH

A

–> blocks endothelin, a vasoconstrictor with proliferative effects
- Bosentan (Tracleer)
- Ambrisentan (Letairis)
- Macitentan (Opsumit)

BBW: restricted access programs: embryo-fetal toxicity, Bosentan: hepatotoxicity

SEs: headahce, edema, hypotension, flushing

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6
Q

Phosphodiesterase-5 (PDE-5) Inhibitors for PAH

A

–> cause pulmonary vasculature relaxation and vasodilation

-Sildenafil (Revatio): 20 mg TID, taken 4-6 hhrs apart, avoid use for PAH in pts taking PI-based regimens

-Tadalafil (Adcira): 40 mg daily, avoid if crcl < 30

SE: dizziness, hypotension, headache
CI w/ nitrates

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7
Q

Soluble Guanglate Cyclase (sCG) stimulator for PAH

A

-Riocigulat (Adempas)
- used for group 1 and group 4
–> lots of drug interactions!

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8
Q

Select drugs that can cause pulmonary fibrosis*

A

-Amiodarone/dronedarone
-Bleomycin
-Busulfan
-Carmustine
-Lomustine
-Nitrofurantoin
-Sulfalazine

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9
Q

Pulmonary Fibrosis

A

-presents as exertional dyspnea with nonproductive cough

Drugs that tx: pirfenidone (Esbriet) and nontedanib (Ofev) –> slow the rate of lung function decline

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10
Q

Diagnosis and assessment of Asthma

A

via spirometry
-FEV1: how much air can be forcefully exhaled in 1 second
-FVC: the max volume of air that is exhaled after taking a deep breath
-FEV1/FVC: the percentage of total air capacity (vital capacity) that can be forcefully exhaled in 1 sec

Criteria: measure FEV1 –> give bronchodilator –> measure FEV1 –> inc FEV1 > 12% = reversibility/diagnosis

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11
Q

Initial asthma assessment (symptom frequency per step & rescue inhaler use)

A

Step 1:
–> < 2 times per month daytime
–> no nighttime
- < 2 days/week

Step 2:
–> > 2x/month daytime
–> < 4-5 days/day nighttime
- > 2 days/week but not daily or >1 x/day

Step 3:
–> most days
–> >1 x/week nighttime
-daily

Steps 4&5:
–> daily
–> > 1x/week nighttime
-several times per day

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12
Q

Asthma Treatment Algorithm: step 1

A

-symptoms < 2x/month
–> PRN low dose ICS + formoterol
OR
–> low dose ICS + SABA

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13
Q

Asthma Treatment Algorithm: step 2

A

-symptoms/need for SABA 2x/month
–> low dose ISC daily
OR
–> low dose ICS + SABA

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14
Q

Asthma Treatment Algorithm: Step 3

A

-symptoms on most days or waking at night >1 x/week
–> low dose ISC + LABA

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15
Q

Asthma Treatment Algorithm: Step 4

A

-daily symptoms, waking at night > 1x/week
–> medium dose ICS + LABA

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16
Q

Asthma Treatment Algorithm: step 5

A

-severe persistent
–> high. dose ICS + LABA
-refer for assessment

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17
Q

Beta 2 agonists: SABAs

A

–> albuterol, levalbuterol
-PRN use only, not rec to use SABA alone
-200 inhalations/canister
-ProAir RespiClick: dry powder formulation
-Primatene Mist- OTC epinephrine

SEs: nervousness/tremor, tachycardia, palpitations, cough, inc BG, dec K

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18
Q

Controller/Maintenance Inhalers for asthma: ICS

A

–> Beclomethasone (QVAR RediHaler)
–> Budesonide (Pulmocort Flexhaler)
–> Fluticasone (Flovant HFA, Flovant Discus, Arnuity Ellipta)

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18
Q

Beta-2 Agonists: LABAs

A

–> salmeterol, formoterol
BBW: inc risk of asthma related death when used as monotherapy
-only use as add on to ICS therapy
-formoterol used for rescue WITH ICS

SEs: nervousness/tremor, tachycardia, palpitations, cough, inc BG, dec K

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18
Q

Inhaled corticosteroids for asthma

A

–> 1st line tx for persistant asthma for all pts, even children
-used PRN w/ fomoterol or SABA for rescue
Warnings: adrenal suppression w/ prolonged use of high doses = growth retardation in children
SEs: dysphonia, oral candidiasis (thrush), cough, inc BG

-Beclomethasone (QVAR RediHaler)
-Budesonide (Pulmicort Flexhaler)
-Fluticasone (Flovant HFA)

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19
Q

Controller/Maintenance Inhalers for COPD: ICS

A

there is no single ICS product that is FDA approved for COPD

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20
Q

Controller/Maintenance Inhalers for asthma: LABA

A

Salmeterol (Serevent discus)

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21
Q

Controller/Maintenance Inhalers for COPD: LABA

A

-Salmetrol (servent discus)
-Formoterol (Performomist - neb)
-Arfomoterol (Brovana - neb)
-Olodaterol (Striverdi Respimet)

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22
Q

Controller/Maintenance Inhalers for asthma: LAMA

A

Tiotropium (Spirivia Respimet)

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23
Controller/Maintenance Inhalers for COPD: LAMA
-Tiotropium (Spiriva HandiHaler, Spiriva Respimet) -Adidinium (Tudorza Pressair) -Glycopyrrolate (Lonhala magnair- neb) -Revefenacin *Yuperli-neb) -Umeclidinium (Incruse Ellipta)
24
Controller/Maintenance Inhalers for asthma: ICS/LABA
-Budesonide/formoterol (Symbicort) -Fluticasone/salmeterol (Advair Discus, Advair HFA) -Mometasone/formoterol (Dulera) -Fluticasone/Vilanterol. (Breo Ellipta)
25
Controller/Maintenance Inhalers for COPD: ISC/LABA
-Budesonide/formoterol (Symbicort) -Fluticasone/salmetrol (Advair Diskus) -Fluuticasone/vilanterol (Brea Ellipta)
26
Controller/Maintenance Inhalers for asthma: LABA/LAMA
-none are FDA approved
27
Controller/Maintenance Inhalers for COPD: LABA/LAMA
-Aclidinium/formoterol (Duaklir Pressir) -Glycopyrrolate/formoterol (Bevespi Aerosphere) -Tiopropium/olodaterol (Stiolato Respimat) -Umelidinium/vilanterol (Anoro Ellipta)
28
Controller/Maintenance Inhalers for asthma: LABA/LAMA/ICS
umelclidinium/vilanterol/fluticasone (Trelegy Ellipta)
29
Controller/Maintenance Inhalers for COPD: LABA/ALAMA/ICS
-umelclidinium/vilanterol/fluticasone (Trelegy Ellipta) -Glycopyrrolate/formoterol/budesonide (Breztri Aerosphere)
30
MDI inhalers*
-HFA, Respimat or no suffix (Symbicort, Dulera) -aerosolized liquid -some use a propellant (HFA) -take slow deep inhalation while preparing the canister -spacer can be used -shake all products EXCEPT QVAR handHaler, Alvesco and Respimat products -prime before first use and if not used for a certain period of time
31
DPI Inhalers*
-Brand names: Diskus, Ellipta, Pressair, HandiHaler, RespiClick, Flexhaler -fine powder -no propellant- needs forceful inhale -admin via fast inhale -spacer cannot be used -do not shake -priming is not needed except for Flexhaler
32
Leukotriene Modifying agents for asthma
-->Montelukast (Singulair) - 1 yr and older -take in the evening -neuropsychriatic events --> Zafirlukast (Accolate) --> Zileuton (Zyflo) -liver damage
33
Theophylline for asthma
-dosed using IBW (if TBW < IBW- use total) SE: nausea, headache, tachycardia, insomnia, tremor Toxicity = arrhythmias, seizures -conversion to aminophylline (Amino To Theoph Mult by 0.8) -range = 5-15 mcg/mL*
34
Anticholinergics (Inhaled muscarinic anntagonists) for anthma
Tiotropium (Spiriva Respimat) for pts 6 yrs and older
35
Monocolnal antibodies (parenteral products) for asthma
-Omalizumab (Xolair) blocks IgE binding to the IgE receptors on mast cekks BBW: anaphylaxis- must be given in healthcare setting -indicated for moderate to severe allergic asthma -given SQ q 2-4 weeks
36
Interleukin receptor antagonists for asthma
--> indicated for severe asthma with an eosinophilic phenotype -Mepolzumab (Nucala): SC q 4 w -Reslizumab (Cinqair): IV q 4 weeks -Benralizumab (Fasenra): SC q 8w -Dupilumab (Dupixent) sc q 2 w
37
Asthma control in pregnancy
-down titration of meds not necessary -rescue inhaler is a must! -preferred controllers: ICS (typically budesonide)
38
spacers for asthma
-helpful for children and anyone that has difficulty with hand-breath coordination with an MDI -plus, spacers reduce the risk of thrush from ICS --> ex: AeroChmaber, OptiHaler, OptiChamber
39
Peak Flow Meter
-green zone = >80-100%: indicates all clear/good control -Yellow zone = 50-80%: indicates caution, worsening lung function -Red zone = <50% personal best: indicated medical alter, seek medical attention -action of plan - rescue inhaler, ED visit -measure PEFR in the am when pt wakes- before asthma meds
40
Counseling tips: Ventalin HFA, Proair HFA
-rinse mouth piece with warm water, clean at least weekly -shake and spray 4 times to prime
41
Diagnosis of Asthma
-age of onset usually < 40 y/o -smoking hx uncommon -sputum production infrequent -allergies common -intermittent/variable symptoms -stable disease (does not worsen over time) -exacerbations common -first line tx: ICS
42
Diagnosis of COPD
-age of onset > 40 y/o -smoking hx usually > 10 yrs -sputum production common -allergies uncommon -persistent symptoms -disease worsens over time -exacerbation common -first line tx: bronchodilators
43
COPD tx: Group A
-CAT <10, mMRC 0-1 with 0-1 exacerbations with NO hospitalization -bronchodilator (preferred) -SABA or SAMA (PRN), LABA or LAMA
44
COPD tx: Group B
-CAT > 10, mMRC > 2 with 0-1 exacerbations with NO hospitalization LAMA or LABA
45
COPD tx: Group C
CAT < 10, mMRC 0-1 with >2 or > 1 exacerbations that lead to hospitalizations -LAMA
46
COPD tx: Group D
CAT > 10, mMRC > 2 with >2 or > 1 exacerbations that lead to hospitalizations -LAMA -LAMA + LABA -LABA + ICS (if eos > 300 cells)
47
COPD escalation of treatment: Dyspnea
LAMA or LABA --> LAMA + LABA --> switch inhalers, check for other causes
48
COPD escalation of treatment: Exacerbations
LAMA or LABA ---> Path 1: EOS > 300: LABA + ICS --> consider roflumilast or azithromycin Path 2: EOS < 300: LAMA + LABA --> -EOS > 100: LAMA + LABA + ICS --> consider roflumilast or azithromycin -EOS < 100: consider roflumilast or azithromycin
49
COPD: short acting muscarinic antagonists (SAMAs)
-Ipratropium bromide (Atrovent HFA) -Ipratropium bromide + albuterol (Combivent Respimat) -QID dosing SE: dry mouth, avoid spraying in the eyes
50
COPD: Long acting muscarinic antagonists (LAMAs)
-Tiopropium (Spirivia HanidHaler, Sprivia Respimat) -Glycopyrrolate/fomoterol/budesonide (Breztri Aerosphere) -Umeclidinium/velantrol/fluticasone (Trelegy Ellipta) -daily ( 2 puffs) dosing SE: dry mouth, avoid spraying in the eyes
51
COPD: Long acting beta-2 agonists (LABAs)
-salmerterol/fluticasone (Advair Diskus) -formoterol/budesonide (Symbicort) -formoterol/glycopyrrolate/budesonie (Breztri Aerosphere) -Vilanterol/fluticasone (Breo Ellipta) -Vilanterol/umeclidinium/flutivasone (Trelegy Ellipta) BBW: asthma related death when used alone SEs: nervousness/tremor, tachycardia, palpitations, cough, inc BG, dec K
52
COPD: Phosphodiesterase-4 inhibitor
--> Roflumilast (Daliresp) -oral tab taken daily -should be used with at least one long acting bronchodilator CI: moderate-severe liver impairment SE: diarrhea, weight loss Drug interactions!!
53
Pack-year smoking hx formula
(cig packs)/day * number of yrs smoked
54
what enzyme does smoking induce?
CYP1A2 --> if you take a CYP1A2 substrate (liek warfarin) = decreased substrate concentrations
55
Women > 35 y/o and smoking:
should NOT take estrogen-containing oral contraceptives = inc risk of cardiovascular events
56
Vaccinations in smokers
-annual influenza vaccine is rec for all persons -smokers age 19-64 should also receive: Pneumococcal vaccine --> Prevnar 20 (PCV20) --> Vaxneuvance (PCV15) followed by Pneumovax 23 (PPSV23)
57
Nicotine replacement therapy: OTC
-Nicotine patch (Nicoderm CQ)- remove before MRI -Nicotine gum (Nicorette) -Nicotine lozenge (Nicorette Mini) -gum and lozenge = sugar free, in 4 mg dose can reduce or delay weight gain
58
Nicotine replacement therapy: RX
-nicotine inhaler (Nicotrol) -nicotine nasal spray (Nicotrol NS)
59
Nicotine replacement therapy SEs
Warnings: avoid in immediate post MI period, life-threatening arrhythmias, angina and pregnancy SE: insomnia, nervousness, HA, patch= vivid dreams
60
Nicotine patch dosing: smokes > 10 cig/day
Start: 21 mg patch x 6 weeks --> 14 mg patch x 2 weeks --> 7 mg patch x 2 weeks -can be longer than 10 week duration, can be used indefinitely
61
Nicotine Patch Dosing: smokes
start: 14 mg patch x 6 weeks --> 7 mg patch x 2 weeks
62
Nicotine gum/lozenge dosing: 1st cig < 30 mins after waking
Start (>9 pieces/day in first 6 weeks): 4 mg Q 1-2 H x 6 w --> 4 mg Q2-4 H x 3 w --> 4 mg Q 4-8 H x 3 w
63
Nicotine gum/lozenge dosing: smokes 1st cig > 30 mins after waking
Start (>9 pieces/day in first 6 weeks): 2 mg Q1-2H x 6 weeks --> 2 mg Q2-4H x 3 weeks --> 2 mg Q4-8H x 3 weeks
64
Bupropion SR (Zyban)
-12 hr formulation -start at least 1 week before quit fate: 150 mg QAM for 3 days, then 150 mg BID (MDD: 300 mg), use for up to 6 months, no need for taper BBW: suicidal thinking in those < 24 y/o CI: seizure disorder, anorexia/bulimia, use with MAOi, linezolid, meth blue,, do not use with any other form of bupropion SE: serious neuro events, dry mouth, insomnia (take in the am), tremors and weight loss
65
Varenicline (Chantix)
-blocks nicotine from binding -0.5 mg tabs (11) 1 mg tab (42) - has taper up schedule -use for 12 weeks Warnings: serious neuro symptoms, seizures SE: nausea (take after food w/ full glass of water), insomnia, abnormal dreams
66
Treatment considerations for tobacoo cessation
-Weight gain? use NRT gum, lozenge (4 mg dose), bupropion SR -Depression? use Bupropion SR -Dentures? avoid gum -Asthma/COPD?: avoid NRT inhaler and nasal spray -skin conditions? avoid patch -seizures? avoid Bupropion, varenicline
67
Nicotine Patch Administration
-remove patch, save pouch -apply the sticky side of patch to a clean, dry area -press patch firmly into skin for ~10 secs -wear for 24 hrs -fold sticky ends together, place in pouch to discard -rotate the application site -never cut the patch and remove before an MRI
68
How to chew nicotine gum
-chew slowly until tingle or pepprey flavor -park gum in between the cheek and gum line -when tingle/flavor goes away, chew until it returns -park again between cheek and gum line -repeat cycle until most of the tingle/flavor is gone -do not eat/drink for 15 min before or while chewing
69

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