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Respiratory Flashcards

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1
Q

ASTHMA PATHO

A

chronic INFLAMMATORY disorder of airways

symptoms at night or in early morning

REVERSIBLE airway obstruction

INC responsiveness to stimuli

**each acute exacerbation causes structural remodeling of airways = thickening of bronchial/bronchiolar mucosa, submucosa, and smooth muscle layers

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2
Q

ASTHMA drug therapy

A

Beta 2 agonists
glucocorticoids
leukotriene modifiers
methylxanthines
anticholinergics
anti-IgE treatment

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3
Q

COPD drug therapy

A

choice of therapy dependent on:
1) availability of med
2) patient’s response

Inhaled therapy (preferred method)
anticholinergics
B2 agonists
glucocorticoids

other routes:
methylxanthines
phosphodiesterase-4 inhibitors

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4
Q

GOLD guidelines

A

GROUP A (MILD): bronchodilator

GROUP B: LAMA/LABA (if persists, combine both)

GROUP C: INC exacerbations = LAMA + (LABA or ICS)

GROUP D (VERY SEVERE): LAMA + (LABA + ICS + additional) (pulmonology referral)

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5
Q

BETA 2 Agonists MOA

A

stimulate B2 receptors in the airways

bronchodilation, smooth muscle relaxation, mast-cell membrane stabilization

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6
Q

BETA 2 Agonists Adverse effects

A

INC HR
Shakiness
Arrhythmias
Restlessness
Tremors
Dizziness
HA

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7
Q

BETA 2 Agonists Contraindications/Special considerations

A

ASTHMA: acute attacks
SABA = rescue
LABA = maintenance/control

COPD: subjective improvement; quality of life
SABA = acute exacerbations
LABA = sustained bronchodilation, more convenient dosing, no rescue use

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8
Q

BETA 2 Agonist Interactions

A

most common:
digoxin
tricyclic antidepressants (TCA)
MAOI
BB

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9
Q

BETA 2 Agonists Patient education

A

Meter-dosed inhaled forms use spacer = Children

PREGNANCY: terbutaline safe; albuterol best SABA; ICS for long-term control

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10
Q

Glucocorticoids medications

A

Inhaled:
beclomethasone MDI
budesonide MDI
flunisolide MDI
fluticasone MDI
mometasone - adult only
triamcinolone MDI

Systemic: PO
oral - prednisone and methylprednisolone

parenteral - methylprednisolone and dexamethasone

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11
Q

Glucocorticoids MOA

A

inhibit synthesis and release of inflammatory mediators

INC number and responsiveness of B2 receptors (improve lung function when combined w/ LABA in COPD)

DEC mucous production and hypersecretion

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12
Q

Glucocorticoids ASTHMA

A

Inhaled are preferred controller tx

step 2 preferred tx

systemic are used only for hard to control asthma; if introduced early in acute attacks can help to reverse inflammation and speed recovery

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13
Q

Glucocorticoids COPD

A

ICS

FEV1 <50% predicated and repeated exacerbations

reversible factors = acute inflammation d/t viral infection and pollutions

scarring and chronic inflammation in COPD are NOT reversible

only thing that helps stop the decline of FEV1 is to STOP SMOKING

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14
Q

Glucocorticoids Adverse effects

A

inhaled - oropharyngeal candidiasis and dysphonia

systemic - HPA axis suppression, growth retardation, DEC bone mineral density, hyperglycemia, steroid myopathy, weaken blood vessels, DEC skin thickness

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15
Q

Glucocorticoids Contraindications/Special considerations

A

Contraindications:
acute attacks
children, especially PO form

Interactions: Azoles

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16
Q

Glucocorticoids Patient education

A

rinse mouth after using inhaler

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17
Q

Leukotriene modifiers MOA

A

ALLERGY MANAGEMENT

inhibit action of leukotrienes

smooth muscle contractions, DEC inflammation, edema, mucus secretions
INC bronchodilation

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18
Q

Leukotriene modifiers medications

A

montelukast (singulair)
zafirlukast (accolate)
zileuton (zyflo)

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19
Q

Leukotriene modifiers ASTHMA

A

NO ACUTE ATTACKS

alternative tx in asthma

ADD to steps 3-4

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20
Q

Leukotriene modifiers COPD

A

NO ROLE IN TX

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21
Q

Leukotriene modifiers Adverse effects

A

HA
GI upset
Resp infections (older adults)

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22
Q

Leukotriene modifiers Contraindications/Special considerations

A

No inhaled, PO meds only

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23
Q

Leukotriene modifiers Patient education

A

montelukast - once daily, BEST in evening

zafirlukast - BEST on empty stomach

Zileuton - no regards to meals

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24
Q

Methylxanthines MOA

A

DEC mast cell mediator release

bronchodilation, enhance mucociliary clearance, INC contraction of fatigued diaphragm

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25
Methylxanthines DOC
Theophylline
26
Methylxanthines ASTHMA
STEP 3-5 NOT for monotherapy
27
Methylxanthines COPD
mild bronchodilator 3rd line agent d/t NARROW TI
28
Methylxanthines Adverse effects
CNS, GI, CV uncommon serum level below 20 see ADEs serum level 15-20
29
Methylxanthines Contraindications/Special considerations
Contraindications: NO PREGNANCY - cross placenta sensitivity to caffeine, xanthine seizure disorders PUD Interactions: metabolized by CYP450
30
Methylxanthines Patient education
1) dosed by patient's weight and serum level 2) NARROW TI = serum monitoring 3) risk of toxicity Caffeine is methylxanthine report sx take med exactly as prescribed
31
Anticholinergics MOA
inhibit cholinergic receptors inhibit parasympathetic action produces bronchodilation, DEC mucous secretions
32
Anticholinergic meds
Ipratropium (atrovent) MDI = COPD Tiopropium (spiriva) MDI = ONLY COPD
33
Anticholinergic ASTHMA
alternative to SABA NO chronic asthma ACUTE ATTACKS
34
Anticholinergic COPD
ALL STAGES COPD Add to SABA in acute COPD
35
Anticholinergics Adverse effects
CAN'T SEE, PEE, SHIT, SPIT restlessness dizziness HA GI distress blurred vision palpitations urinary obstruction
36
Anticholinergics Contraindications/Special considerations
contraindications: hypersensitivity to ATROPINE, acute bronchospasm Caution: narrow-angle glaucoma, BPH, Pregnancy, lactation
37
Anticholinergics Patient education
MDI and neb forms when inhaled, confined to mouth/airways
38
Anti-IgE treatment meds
Omalizumab (xolair) injectable
39
Anti-IgE treatment ASTHMA
STEP 5 IgE >30 allergic asthma if uncontrolled on standard tx mod-sev asthma = ICS not effective
40
Anti-IgE treatment Adverse effects
HA injection site reaction upper resp tract infection
41
Anti-IgE treatment Contraindications/special considerations
NOT for acute asthma attacks
42
Anti-IgE treatment Patient education
PREGNANCY SAFE BLACK BOX: anaphylaxis monitor for sx and improvement in QOL, use of rescue meds, Not serum IgE dosed every 2-4 wks by body weight dose/dose frequency are determined by pre-treatment IgE levels
43
Allergic Conjunctivitis
DOC: ophthalmic H1 blocker Ketotifen adults and children >3 dose: 1 drop in affected eye Q8-12 hours OTC products: combine decongestant and antihistamine
44
COPD PATHO
chronic bronchitis/emphysema disease state characterized by airflow limitation that is NOT FULLY REVERSIBLE usually progressive associated w/ an abnormal inflammatory response of the lungs to noxious particles of gas INC exacerbations = DEC baseline
45
COPD Diagnostic criteria
determined by spirometry tests of lung function positive diagnosis made when the ratio of FEV <70%
46
COPD Stages
1) At risk (smokers, exposed to smoke, cough, dyspnea, sputum, family hx) = FEV1 >0.7 FEV1 > 80% of predicted 2) Mild = FEV1 <0.7; >80% of predicted 3) Moderate = FEV1 <0.7; 50%
47
COPD Goals of therapy
1) address symptoms and quality of life 2) health education 3) pharmcotherapy
48
COPD Patient education
1) smoking cessation 2) patho COPD understanding 3) medication skills 4) specific drug therapy 5) reasons for drugs being taken 6) drugs as part of the total treatment regimen 7) adherence issues
49
COPD Vaccines
Influenza vaccine - annually; earlier the better pneumococcal vaccine - every 6 years
50
Smoking Cessation: Questions to ask
1) is patient ready to quit smoking?
51
Smoking cessation: Nicotine
adjunct to smoking cessation program MOA: vasoconstrictor SE: CNS: peripheral vasoconstriction, tachycardia, HA, paresthesia, fatigue, insomnia, nausea, hot flashes, **nightmares GI: N/V/D, dry mouth, dyspepsia Nasal spray: irritation, cough, sneezing Patch: skin irritation, burning CONTRAINDICATIONS: NO PREGNANCY - cross placenta NO LACTATION - in breast milk **NOT used immediately after MI, those w/ arrhythmias, severe angina MED admin: patch 21 mg >or= 1 ppd 14 mg = 1/2 ppd Patient education: 1) AVOID smoking = overdose or toxicity 2) Be aware sleep disturbances 3) Inspect oral cavity = using gum 4) teach to use system correctly
52
Smoking Cessation: Bupropion
Zyban (brand) Wellbutrin - antidepressant SE: INC HR HA insomnia dizziness xerostomia weight loss nausea pharyngitis Contraindications: seizure disorders, eating disorders, MAOI use Med admin: 1) dose 150mg/day x3 days, then BID 2) suggested use 12 wks 3) start 1 wk before quit date 4) DEC seizure threshold 5) INC libido Patient education: 1)BLACK BOX: suicidal thinking 2) AVOID ETOH = INC depression 3) can combo w/ nicotine patches = BETTER 4) report resp difficulties, unusual cough, dizziness, or muscle tremors
53
Smoking Cessation: Varenicline
Chantix (brand) MOA: partial agonist w/ high affinity and selectivity for alpha4-beta2 nicotine acetylcholine receptor SE: insomnia, HA, abnormal dreams Precautions: NO PREGNANCY NO LACTATION pre-existing psych disorders NO children <18 Med admin: 1) 12 wk intervention program 2) dose adjustment for RENAL impairment 3) complete patient education program 4) start 1 wk before quit date 5) can DEC dose if experiencing ADEs Patient education: **Neuropsych sx reported w/ use and withdrawal of med = INC anger give w/ food and water to DEC GI effects
54
Why is it hard for smokers to quit?
nicotine addition not ready to quit
55
Respiratory ALLERGIES
antihistamines 1st GEN: benadryl ADE: drowsiness adult dose: 25-50 mg Q4-6 hours IF patient cannot TOLERATE 1st Gen = 2nd GEN can be given cetirizine (children >12) = 5-10 mg/day daily children 6-11 = 5-10 mg once daily renal impairment = fexofenadine 60 mg once daily renal/liver disease = loratadine 10mg every other day renal/liver impairment = desloratadine given every other day
56
When to use ORAL (eye/nasal) drugs
57
When to use TOPICAL (eye/nasal) drugs
58
COUGH: med types
antitussive expectorant
59
COUGH: Antitussives
dextromethorphan (DM) codeine benzonatate
60
COUGH: Expectorants
guaifenesin
61
ANTITUSSIVE: Dextromethorphan
INDICATION: dry, hacking, non-productive cough works directly on cough center in medulla chemically related to opiates rapidly absorbed from GI INTERACTIONS: CNS depressants, MAOI, fluoxetine, quinidine, sibutramine, ETOH adolescent abuse; can overdose Pregnancy: CAUTION near term AE rare: N/V, irritability, serious drowsiness, dizziness administer evenly spaced intervals equally as effective as codeine ALCOHOL/SUGAR content: CAUTION in DM, ETOH, taking FLAGYL
62
ANTITUSSIVE: Codeine-scheduled drug
Works directly on cough center Drying effect on mucous and can INC viscosity of secretions metabolized by liver P-450 PREGNANCY - crosses placenta NO LACTATION - enters breast milk CONTRAINDICATIONS: other narcotics, those who NEED productive cough abuse potential CAUTION in children and elderly AE: drowsiness, sedation, dry mouth, N/V, constipation respiratory depression in HIGH doses Interactions: antihistamines, barbiturates, histamine 2 blockers, phenothiazines EDUCATION: measure correctly, do NOT share, warn about sedation
63
ANTITUSSIVE: Benzonatate tessalon perles - gel capsule
Non-narcotic anesthetizes stretch receptors in resp tract to DEC cough reflex no known interactions PREGNANCY: caution, only if clearly indicated NO LACTATION NO CNS depression adults and children >10 must swallow whole AE: drowsiness, HA, dizziness, GI upset, pruritus, skin eruptions
64
EXPECTORANT: Guaifenesin robitussin mucinex
Non-productive dry cough MOA: enhances output of resp tract fluids; DEC stickiness and surface tension of fluids THINS MUCUS onset 30 mins no drug interactions PREGNANCY; CAUTION may use in children >6 NO ETOH AE: N/V, anorexia, HA, dizziness take w/ full glass of water
65
COUGH meds warnings
1) active ingredients are often mixed cough suppressant and expectorant 2) cancel each other out 3) patient may be taking multiple products w/ same active ingredients 4) WATCH acetaminophen and ETOH levels 5) NEVER use more than 3-7days 6) NOT recommended for children <6
66
Antihistamines CONTRAINDICATIONS/PRECAUTIONS
CONTRAINDICATIONS: narrow angle glaucoma LRI PUD BPH MAOI CAUTION: urinary retention asthma hyperthyroidism CV HTN ANTICHOLINERGIC EFFECTS
67
Antihistamines 1st Gen MOA/USES
H1 receptor blockers: blocks action of histamine released during inflammatory response restores normal airflow to the upper resp system ALLERGIC RHINITIS
68
Antihistamines 1st Gen DOC
Diphenhydramine (benadryl) IM, IV, PO forms indicated: allergic disorders where PO form is impractical or contraindicated adjunct in anaphylaxis allergic rxn to blood/plasma products NOT recommended in neonates, premature infants, ACUTE ASTHMA
69
Antihistamines 1st Gen what to know
oldest sedating (cross BBB) = drowsiness NO LACTATION = dry breast milk NO children <6 can cause CNS stimulation (HYPER) in children Interactions: MAOI, CNS depressants, TCAs, antimuscarinics PREGNANCY SAFE
70
Antihistamines 2nd Gen MOA/USES
seasonal and perennial allergic rhinitis allergic conjunctivitis urticaria angioedema **most effective before onset of sx (seasonal and perennial allergic rhinitis)
71
Antihistamines 2nd Gen Meds
cetirizine (zyrtec) fexofenadine (allegra) loratadine (claritin) desloratadine (clarinex)
72
Antihistamines 2nd Gen what to know
longer acting less sedating (no cross BBB) enters breastmilk = NO LACTATION do NOT given w/ CNS depressants, other H1 blockers, macrolides (torsades) CAUTION: certain antibiotics, antifungals, children <6 give w/ or w/o food **most effective before onset of sx (seasonal and perennial allergic rhinitis)
73
Antihistamines INHALED
SEASONAL ALLERGIC RHINIITS AND VASOMOTOR RHINITIS H1 blocker and inhibitor from mast cells may interfere w/ histamine and leukotriene induced bronchospasm SE: epistaxis, throat irritation, BAD taste
74
Decongestants phenylephrine pseudoephedrine
DEC nasal congestion = opening ALPHA ADRENERGIC AGONISTS constrict nasal arterioles = DEC nasal swelling may constrict GI/GU sphincters HIGH abuse potential Pregnancy C Caution in children <12 contraindications: MAOI, BB, TCA NO patient w/ HTN, CAD AE: CNS related anxiety, restlessness, tremors, insomnia, convulsions, hallucinations CV effects: INC BP, tachycardia, arrhythmias extreme dryness of mucus membranes PO no longer than 4 days use; topical 48-72 hours = risk rebound congestion
75
NASAL Steroids beclomethasone
ALLERGIC RHINITIS work better than PO antihistamines minimal systemic effects and AEs long term or high dose may cause systemic reaction ADEs: burning, itching, drying sensation Dose on regular or PRN schedule
76
Inhaled Mast Cell Stabilizer
intranasal Cromolyn sodium shields mast cells lining nasal passage and prevents histamine release use 4-6 xday PREGNANCY SAFE
77
Inhaled Anticholinergic Agents
intranasal Ipratropium bromide DEC watery nasal secretions in upper resp passages No significant relief for other sx adults and children >6 pregnancy B NO IF ALLERGY TO ATROPINE AE: epistaxis, pharyngitis, nasal dryness or irritation
78
Non-pharmacological decongestant therapies
nasal strips - hold open nasal passage vapor inhaler - vasoconstrictor; will cause HTN, tachycardia adults and children >2 no more than 7 days

Pharmacology (12 decks)

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