Week 6 Respiratory Part 2 Flashcards
1
Q
What is characterized by variable airflow obstruction-often reversible (esp with meds)?
A
asthma
2
Q
What causes the airflow obstruction in asthma?
A
bronchial hyper-responsiveness (BHR)- various triggers causing chronic airway inflammation-airway remodeling
3
Q
What is the most common chronic disease of children?
A
asthma (7%)
4
Q
How many deaths are there a year from asthma?
A
5,000 deaths/year
5
Q
What percentages of asthma deaths are preventable?
A
80-90%
6
Q
Where do most of the asthma deaths occur?
A
Out of the hospital
inadequate therapy
7
Q
Asthma is caused by infiltration of what?
A
eosinophils & mast cells
8
Q
What are some of the mediators in asthma? (3)
A
prostaglandins
thrombaxanes
leukotrienes
9
Q
What are the prostaglandins that cause bronchicontriction in asthma?
A
D2 and F2 alpha
10
Q
What is the effect of thrombaxanes in asthma?
A
bronchiconstriction/inflammation
11
Q
What are the leukotrienes involved in asthma?
A
C4, D4, E4= SRS-A
12
Q
What are the bronchodilators for asthma?
A
beta 2 agonists
anticholinergics
theophylline
13
Q
What are the anti-inflammatory agents for asthma?
A
inhaled glucocorticosteroids (ICS)
14
Q
What are the pharmacotherapy targets for asthma?
A
bronchodilators
anti-inflammatory agents
leukotriene receptor antagonists (LTRAs)
Anti-Interleukin 5 antibodies (IL-5)
15
Q
How is asthma severity classified?
A
frequency of symptoms
severity of symptoms
16
Q
How is asthma diagnosed?
A
abnormal PFTs that improve by 15% or more after bronchodilator therapy
17
Q
What is the cornerstone of asthma treatment?
A
pharmacotherapy
18
Q
What are the 2 main therapeutic options for asthma?
A
bronchodilators and inhaled corticosteroids
19
Q
What are the bronchodilators used for asthma?
A
beta agonists: rescue inhalers for acute exacerbations
20
Q
When are anticholinergics mostly used as bronchidilators?
A
less with asthma and more with COPD
21
Q
What medication suppresses the underling inflammation caused by asthma?
A
imahuled corticosteroids
22
Q
What is an example of a leukotriene receptor antagonist?
A
montelukast
23
Q
What is the goal of step 1-intermittent treatment?
A
long term control: none
Quick relief: short acting bronchodilator (SABA PRN)
24
Q
What is the treatment regimen for step 2-mild persistent?
A
long term control:
preferred: low dose ICS
alternativeL an LTRA (montelulast)
quick reliefL SABA
25
What is the treatment regimen for step 3-moderate persistent?
long term:
low dose ICS+ LABA (preferred)
alternative: medium dose ICS OR low dose ICS+ LTRA
Quick relief: SABA
26
What is the treatment regimen for step 4- severe persistent?
long term:
medium or high dose ICS + LABA (preferred)
Alternative:
medium or high dose ICS+ LAMA OR high dose ICS +LTRA or theophylline
Quick relief: SABA
27
What are the most effective bronchodilators that are indicated for intermittent bronchospasm, of asthma?
beta 2 agonists
28
What are the drugs of choice for acute asthma and exercise induced bronchospasm (EIB)?
beta 2 agonists
29
How is bronchoselectivity increased with beta 2 agonists?
increased by inhalation
30
What are the 2 categories of beta 2 agonists?
```
short acting (SABA)
long acting (LABA)
```
31
What are the short acting (rescue) beta 2 agonists?
```
albuterol
levalbuterol
metaproterenol
terbutaline
pirbuterol
```
32
What is the onset and duration of short acting beta 2 agonists?
onset: 1-5 minutes
duration: 2-6 hours
33
What are the long acting (maintenance/control/prophylactic) beta 2 agonists?
salmeterol
formoterol
indacatrol
34
What is the onset and duration of long acting beta 2 agonists?
onset: 5-15 minutes
duration: >12 hours
35
What medication resulted in increased asthma related deaths?
long acting beta 2 agonists (paradoxical increase in exacerbations in some)
36
What are the inhaled steroids that are the most effective anti inflammatories for treating asthma?
corticosteroids
37
When do most pts symptoms improve with corticosteroids?
1-2 weeks
38
What is the advantage of inhaled vs systemic steroids?
inhaled avoids systemic side effects
39
When are high doses of SYSTEMIC corticosteroids used?
for severe asthma or severe asthma unresponsiveness to beta 2 agonists
40
What is the systemic corticosteroid dose for severe asthma?
prednisone 1-2mg/kg/daily (max 60mg/day) divided BID or TID x 3-10 days
41
What is the first line of treatment for persistent asthma?
inhaled steroids
42
What is the toxicity of inhaled steroids?
minimal at low-moderate doses
43
What can reduce systemic absorption and thrush of systemic corticosteroids?
mouth ringing reduces absorption
| BIF dosing reduced thrush
44
What is the IV corticosteroid given for severe asthma?
methylprednisolone
| loading dose 2mg/kg then 0.5-1mg/kg every 6 hours
45
What are common inhaled steroids?
```
Beclomethasone
Triamcinoline (Azmacort)
Flunisolide (aerobid)
Budesonide (pulmicort)
Fluicasone (Flovent)
```
*all equally effective but doses are NOT interchangeable
46
What medication inhibits constrictive "tone"?
anticholinergics
47
Are anticholinergics as potent as beta agonists? Why?
No- quaternary NH 4 agents have poor absorption
48
What are cholinergic antagonist agents?
ipratropium (atrovent)
| tiotropium (spiriva)
49
What is combivent metered dose inhaler (MDI)?
atrovent + albuterol
50
What medication for asthma has potency that is limited by a narrow therapeutic index?
methylxanthines (MXs)
| Theophylline
51
When do toxic effects of methylxanthines (MXs) occur?
>15mg/L
52
What is the therapeutic range of methylxanthines (MXs)?
10-20mg/L (OVERLAP with toxic dose effects)
53
What is the MOA of methylxanthines (MXs)?
phosphodiesterase (PDE) III & IV inhibition
54
What is an example of a leukotriene modifier? (LTM/ LTRA)?
montelukast (singulair)
55
When are leukotriene modifiers best used?
as addicts in patients with more severe asthma
56
What 2 LTM/LTRA interact with warfarin and prolong the INR.
Zafirlukast & Zileuton
57
What medication increased theophylline (MXs) levels AND need to be cut in half if given together?
Zileuton
58
What is the only LTRA with daily dosing?
Montelukast (Singulair)
59
What asthma medications have both caused hepatotoxicity?
Zafirlukast & Zileuton
60
What is an example of an anti-IgE monoclonal antibody for asthma treatment?
Omalizumab (Xolair)
61
What is a complication of Omalizumab (Xolair)?
anaphylaxis occurs in 1-2/1000
62
What medication permits reduction in haled-corticosteroid use?
Omalizumab (Xolair)
63
What is the greatest draw back of Omalizumab (Xolair)?
$10,000-30,000/year
64
What is Omalizumab (Xolair) usually reserved for?
severe-persistent asthma
65
What are 2 FDA approved anti-interleukin 5 antibodies (IL-5) for asthma?
Mepolizumab (Nucala)
Reslizumab (Cinqair)
$$$$$$
66
What is the benefit of anti-interleukin 5 antibodies (IL-5) for asthma?
decreased exacerbations by 50%
67
What is an adverse effect of anti-interleukin 5 antibodies (IL-5) for asthma??
possible anaphylaxis
68
COPD is characterized by airflow obstruction due to what?
chronic bronchitis or emphysema
69
What COPD is characterized by chronic or recurrent excess mucus secretion into bronchial tree?
chronic COPD
70
What are the characteristics of a cough with chronic bronchitis?
most days greater than 3 months/year
| for at least 2 consecutive years
71
Bronchitis is denied in _____ .
clinical terms
72
What COPD is technically definite by anatomic pathology?
emphysema
73
What are the characteristics of emphysema?
permanent enlarged air spaces
| destruction of alveolar walls
74
What COPD presentation involves impressive history of productive cough and called "blue bloaters" due to CO2 retention?
chronic bronchitis
75
With chronic bronchitis, chest percussion is ______.
resonant
76
With chronic bronchitis, breath sounds are _______.
distant to auscultation
77
What COPD presentation usually has increasing dyspnea with minimal cough, and called "pink puffers" due to tachypnea?
emphysema
78
What COPD presents with "pursed lip" which compensates for loss of elastic recoil?
emphysema
79
What COPD often uses accessory muscles for breathing?
emphysema
80
Chest percussion is ______ in emphysema?
hyper resonant
81
What is a major risk factor for both types of COPD?
cigarette smoking
82
How does COPD inflammation differ from asthma?
asthma: caused by eosinophils & mast cells
COPD: caused by neutrophils, macrophages & CD8 T lymphocytes
83
COPD is characterized by _______.
exacerbations
84
What is an acute event characterized by a worsening of the patients respiratory symptoms that is beyond normal day to day variation and leads to a change in mediation?
COPD exacerbation
85
How many exacerbations do pts have a year?
1-2
86
What percentage of exacerbations will be managed outpatient?
more than 80%
87
What severe exacerbations should be admitted to the hospital?
accessory muscle use
cyanosis
peripheral edema
88
What are life-threatening exacerbations that should be admitted to the ICU?
mental status changes
worsening respiratory status despite ventilator support
hemodynamic instability
89
What are the COPD pharmacotherapies?
```
cholinergic antagonists (anti muscarinic agents and anticholinergics)
sympathomimetics (beta agonists)
combo anticholingerics/B2 agonists
inhaled corticosteroids
long term low dose oxygen
antibiotics (for exacerbation ONLY)
```
90
What are the 1st line agents for COPD?
inhaled cholinergic antagonists
91
Why are inhales cholinergic antagonists 1st line in COPD
fewer side effects with sympathomimetics
92
What is second line treatment after anticholinergics in COPD?
sympathomimetics (beta agonists)
93
What is still the drug of choice in acute exacerbations of COPD?
sympathomimetics (beta agonists)
| due to rapid onset
94
When should a trial of sympathomimetics (beta agonists) be used in COPD?
begin a trail if response to ipratropium is unsatisfactory
95
What is significant about ICS in COPD?
DO NOT modify lung function decline OR improve mortality
96
When are ICS recommended in COPD?
pts with severe COPD or pts with frequent exacerbations
97
What are adverse effects of ICS?
oropharyngeal candiasis
| hoarse voice
98
What medication is discouraged long term due to adverse effects?
SYSTEMIC corticosteroids
99
What has been shown to decrease mortality in COPD?
continuous O2 long term
| also improves quality of life and decreases time in the hospital
100
How is long term oxygen administered in COPD?
nasal canula 2-3L/minute
101
What is the goal of COT? (continuous oxygen therapy)
raise PaO2 to >60mmHg
102
What happens in PaO2 is raised too hight?
depress respiratory drive-patients may die in their sleep!
103
Why are antibiotics only used in acute exacerbations with COPD?
only effective in setting od infection
| 7-10 days
104
What abx should be used in COPD exacerbation?
azithromycin for 3-5 days
105
Combinations of what medications usually work better in COPD compared to alone?
anticholinergics and beta 2 agonists
106
What is the controversy when it comes to COPD treatment?
over antibiotics and steroids for acute exacerbation of COPD
107
What is the stepwise drug therapy for COPD algorithm,?
short acting inhaled bronchodilator for acute symptomatic relief
long acting ICS
combination anticholinergic + beta agonist
consider theophylline
combo ICS + LABA
