Asthma and COPD Management Flashcards
Where are B2 adrenergic receptors generally located in the lungs?
- smooth muscle
- trachea down to terminal bronchioles
- ⬆️ noraadrenalin and adrenaline
What are the 5 different methods drugs can be given for asthma and COPD?
1 - inhaled (inhaler and nebuliser)
2 - oral
3 - intravenous
4 - intramuscular
5 - subcutaneous
What is the main benefit of use inhalers and nebulisers to deliver drugs to the lungs?
- direct deposition into the lungs
What is the main disadvantage of use inhalers and nebulisers to deliver drugs to the lungs?
- technique dependent
- disease can reduce drug accessing lungs
- 8-15% of drugs reaches lungs
What is the main benefit of taking asthma and COPD drugs orally?
- not technique dependent
What is the main disadvantage of taking asthma and COPD drugs orally?
- dependent on absorption in GIT
What are the 2 main benefits of taking asthma and COPD drugs intravenously?
1 - systemic effects
2 - not technique dependent
What are the main disadvantage of taking asthma and COPD drugs intravenously?
- ⬆️ risk of side effects
Are inhales and nebulisers fast acting?
- yes
- directly into lungs
Why are inhalers and nebulisers associated with low risk of side effects?
- majority of drugs remains in lungs
- small amount may enter circulation
Does the whole drug dose of the inhaler reach the lungs, even with the best technique?
- no
- aprox 8-15% reaches lungs
Do all inhalers have the same size particles in the aerosol?
- no
- small, medium and large particles
Why is it important to know the particle size of drugs delivered as inhalers or nebulisers?
- particle size affects where in the lungs drug reaches
How can we identify where in the lungs an inhaler or nebuliser reaches?
- lung specific radio-labelling
- radio-label appears on gamma camera
In addition to particle size, how does flow rate affect drug delivery in inhalers and nebbulisers?
- ⬇️ flow rate = poor drug delivery
- ⬆️ flow rate = good drug delivery
Do B2 agonists target adrenoreceptors or muscarinic receptors?
- adrenergic receptors
- Gas specifically
What is the basic pathway once an inhaler has bound to the Gas adrenergic receptor?
- adenylyl cyclase converts ATP to cAMP
- cyclic adenosine monophosphate (cAMP)
- cAMP activates protein kinase A (pKA)
- pKA activates intracellular phosphorylation
How does protein kinase A cause vasodilation and bronchodilation?
- ⬇️ intracellular Ca2+
In addition to bronchodilation, what are the other 2 things that inhalers are able to induce in the lungs that can cause problems in obstructive lung disease?
1 - ⬆️ mucous clearance
2 - ⬇️ vascular permeability
Why is ⬇️ permeability following the use of an inhaler a good thing?
- ⬇️ acute inflammation
What is the core drug used as a short term B2 agonist (SABA) for the treatment of asthma?
- salbutamol
- also known as ventolin
Salbutamol (ventolin) (SABA) is the core drug used as a short term B2 agonist for the treatment of asthma. What is another drug that can often be used?
- terbutaline - also known as terbutaline
What is the core drug used as a long term B2 agonist (LABA) for the treatment of asthma?
- salmeterol
Salmeterol is the core drug used as a long term B2 agonist (LABA) for the treatment of asthma. what is another drug that can often be used?
- formoterol
How quickly can the short acting Salbutamol (ventolin) (SABA) take its affects?
- generally <10 minutes
How long can the effects of the short acting Salbutamol (ventolin) (SABA) last?
- 3-5 hours - max dose several times/day
What are the 3 most common side effects from B2 adrenergic agonists (SABA)?
- tachycardia (B1 receptors in heart)
- termor (B2 in skeletal muscle)
- agitation
Would B2 adrenergic agonists used to treat asthma cause potential side effects on the sympathetic or para sympathetic nervous system?
- sympathetic - adrenergic are only in sympathetics system
Are there likely to be more side effects in inhalers or when B2 adrenergic agonist are given intravenously?
- intravenously - systemic distribution of drug
How quickly can the long acting Salmeterol (LABA) take its affects?
- usually within 30 minutes
How long can the long acting Salmeterol (LABA) affects last?
- 10-12 hours - max dose twice a day
How can the long acting Salmeterol (LABA) be administered?
- inhaler only
Can the long acting Salmeterol (LABA) be administered in isolation like Salbutamol (Ventolin)?
- no - ALWAYS administered with inhaled corticosteroids (ICS) and or LAMA
In addition to treating asthma, what can the combination of long acting Salmeterol (LABA) and inhaled corticosteroids (ICS) be used to treat?
- COPD - common treatment
What is the common core drug used as a short term muscarinic antagonist (SAMA) in the treatment of asthma and COPD?
- Ipratropium Bromide (SAMA) - also known as Atrovent
Ipratropium Bromide (Atrovent) is a short acting muscarinic antagonist (SAMA), which GPCR does it act on?
- M3 muscarinic receptors - Gaq (M1, M3 and M5 are Gaq)
Ipratropium Bromide (Atrovent) is a short acting muscarinic antagonist (SAMA), acting on the Gaq GPCR receptors, how does it cause bronchodilation?
- inhibits Ca2+ release - ⬇️ Ca2+ = brochodilation
What is the basic pathway for Gaq, which muscarinic antagonist act on?
- phospholipase C cleavea PiP2
- PiP2 cleaved into IP3 and DAG
- IP3 binds to sarcoplasmic retculum and ⬆️ Ca2+
- Ca2+ and DAG activate protein kinase C (pKC)
- pKC activates phosphorylation
Ipratropium Bromide (Atrovent) is a short acting muscarinic antagonist (SAMA), how long does it take to have an effect on the patient?
- 30 minutes
Ipratropium Bromide (Atrovent) is a short acting muscarinic antagonist (SAMA), how long do the effects last for?
- 6 hours - can be used up to 4/day
Ipratropium Bromide (Atrovent) is a short acting muscarinic antagonist (SAMA) generally used to treat asthma, but what other obstructive lung disease can it be used to treat?
- COPD - 20-40ug quantum dots (qds) nano carriers for drugs
If a patient has an acute exacerbation of asthma or COPD, why is Ipratropium Bromide (Atrovent), a short acting muscarinic antagonist (SAMA) given via a nebuliser?
- higher dosage of the drug delivered - 250-500ug quantum dots (qds) nano carriers for drugs
Do short term B2 adrenoreceptor agonist (SABA) or short term muscarinic antagonists (SAMA) have a larger bronchodilator effect?
- SABA - SABA and SAMA together are best
Ipratropium Bromide (Atrovent) is a short acting muscarinic antagonist (SAMA), in addition to bronchodilation, what else do they help with in obstructive lung diseases such as asthma and COPD?
- ⬇️ mucus production
Does Ipratropium Bromide (Atrovent), a short acting muscarinic antagonist (SAMA) influence the parasympathetic nervous system?
- minimal effects - muscarinic only in parasympathetic system
What is the common core drug used as a long term muscarinic antagonist (LAMA) in the treatment of asthma and COPD?
- Tiotropium
Tiotropium is a long acting muscarinic antagonist (LAMA), in addition to bronchodilation, what else do they help with in obstructive lung diseases such as asthma and COPD?
- ⬇️ bronchospasm - ⬇️ mucus production
Tiotropium is a long acting muscarinic antagonist (LAMA), how long does it generally last for?
- 12-24 hours - max 2/day
Tiotropium is a long acting muscarinic antagonist (LAMA), how is it administered?
- inhaler
What are some common side effects of long and short acting muscarinic antagomists?
- dry mouth - blurred vision - urinary retention - cardiac arrhythmia’s - dizziness - epistaxis (nose bleeds) - closed angle glaucoma (iris bulges forward)
What are corticosteroids?
- class of steroid hormones
Other than antibiotics, what is the most commonly prescribed drug for lung disease?
- corticosteroids
What is the main purpose for the use of corticosteroids in lung disease?
- anti-inflammation - they do have systemic effects
Where are corticosteroids receptors located in the body?
- on most cells in the body
How do corticosteroids induce their effects in the body?
- hormone so can cross plasma membrane
- binds to glucocorticoid receptor in cytoplasm
- receptor binds to nucleus and enters
- specifically binds to nucleotides
- ⬇️ inflammatory translation and transcription occur
- ⬇️ inflammatory protein translation
What is the most common corticosteroids prescribed orally to patients with lung disease?
- prednisolone
What is the most common corticosteroids prescribed as an inhaler to patients with lung disease?
- beclomethasone
What are the benefits of administering corticosteroids intravenously or orally?
- stronger effects as higher doses available - not technique dependent - better route in the ill and in emergency
What are the disadvantages of administering corticosteroids intravenously or orally?
- ⬆️ risk of side effects - especially in long term treatment
What are the benefits of administering corticosteroids using an inhaler?
- localised action - ⬇️ side effects
What are the disadvantages of administering corticosteroids through an inhaler?
- disease may prevent penetration of drug
Beclomethasone is a corticosteroid used to treat lung disease through inhalers. What are the 3 common side effects associated with them?
1 - immunocompromised, ⬇️ ability to fight infections
2 - oral candidiasis (fungal infection)
3 - dysphonia (croaky voice)
Beclomethasone is a corticosteroid used to treat lung disease through inhalers. Immunocompromised, oral candidiasis (fungal infection) and dysphonia (croaky voice) are common side effects, what can be done to reduce them?
- gargle prior to administration - use spacer for mdi - use turbohaler
What are some short term (days) effects of steroids used in lung disease?
- indigestion - skin bruising - insomnia - psychosis
What are some medium term (weeks) effects of steroids used in lung disease?
- gastric ulcers - skin bruising - insomnia - psychosis - weight gain
What are some long term (months) effects of steroids used in lung disease?
- osteoporosis - growth retardation - weight gain - cushingoid appearance (moon face) - adrenal suppression - hypertension - diabetes
What are the 3 main types of inhaler devices?
1 - pressurised metered dose inhaler with spacer 2 - dry powder inhaler 3 - soft mist inhaler
What are spacers?
- volumetric device with one way valve - ⬆️ space between actuator and mouth - ⬇️ oropharyngeal drug deposition
Why are spacers used with inhalers?
- ⬆️ drug delivery to lungs
What is combination therapy?
- multiple drugs given together - work synergistically
Does combination therapy improve anything other than respiratory symptoms?
- improves patients quality of life
Why is combination therapy used?
- ⬆️ efficacy and max brochodilation - cost effective - ⬆️ compliance
When considering the stepwise guide to treating asthma, is it better to increase a dose of a drug, or to use combination therapy and provide a second different drug?
- combination therapy is best
What is a nebuliser?
- breathing device - able to deliver large dose of drugs as an aerosol
In patients with exacerbations of asthma and COPD, what adrenergic and muscarinic drugs are given through a nebuliser?
- short acting adrenergic agonists - short acting muscarinic antagonists
In addition to providing a large dose of a drug as an aerosol, nebulisers be useful in asthma and COPD to distinguish what?
- distinguish between asthma and COPD
- if asthma symptoms improve rapidly (reversible)
- if COPD symptoms do not improve (non-reversible)
What are methylxanthines?
- non selective phosphodiesterase inhibitors and bronchodilators
Methylxanthines are phosphodiesterase inhibitors, what is the mechanism of action?
- small molecules so can cross plasma membrane
- inhibit breakdown of cAMP, so cAMP ⬆️ in cells
- ⬆️ protein kinase A
- ⬇️ Ca2+ = bronchodilation
Which Methylxanthines is given orally to treat chronic asthma and COPD?
- Theophylline
- T - think Throat
Which Methylxanthines is given intravenously to treat exacerbations of asthma and COPD?
- Aminophylline
- A - think given in the Arm
Does methylxanthines have a large or narrow therapeutic window?
- narrow window
What is a common mucolytic drug?
- drug that breaks down mucus - easier to cough up mucus in COPD
What is the common drug administered as a mucolytic drug?
- Carbocisteine
- C think Cough up mucus
What drug can be prescribed to treat exercise induced asthma that is able to inhibit leukotrienes?
- Montelukast
Oxygen as a drug is used to treat patients with type 1 respiratory failure (PaO2 <7.8 kPA or 60mmHg), what is the target SaO2?
- 94-98%
Oxygen as a drug is used to treat patients with type 2 respiratory failure (PaO2 <7.8 kPA or 60mmHg and PaCO2 >48mmHg or 6.5kPA), what is the target SaO2?
- 88-92%
What can inappropriate use of O2 cause?
- iatrogenic (caused by medical treatment)
- type 2 respiratory failure
- death
- CO2 retention
- acidosis
Is O2 used for patients with breathlessness?
- no
What are the main methods O2 can be delivered to patients?
- nasal cannula
- simple face masks
- re-breathe mask (bag on mask)
- controlled O2 via venturi mask
When is a venturi mask recommended?
- type 2 respiratory failure
In type 2 respiratory failure why is a venturi mask useful when delivering O2 % and rates of flow?
- various levels of O2 can be delivered - various flow rates of O2 can be delivered
When using a venturi mask recommended what is the SaO2 target?
- 88-92%
What is long term O2 therapy?
- O2 given in O2 canisters - patients transport this around with them
Only when O2 drops below a certain level would long term O2 therapy be recommended, what is this level?
- continuously <7.3 kPA or 55mmHg
What respiratory diseases would long term O2 therapy be used in?
- COPD - pulmonary fibrosis - pulmonary hypertension
When treating patients with asthma and COPD with antibiotics, why is it important, where possible to check the sensitivity of the organism?
- antibiotic resistance
When treating patients with asthma and COPD with antibiotics, what must you always do?
- check allergies - drug interactions - drug contradictions
What are 2 of the most common bacteria that cause infection in asthma and COPD?
- streptpcoccus pneumonia
- staphylococcus aureus
What are the common antibiotics prescribed to patients with asthma and COPD for streptococcus pneumonia?
- amoxicillin (penicillin) - clarithromycin (macrolides)
What are the 3 main guidelines set out by the British Thoracic Society and Scottish Intercollegiate Guidelines Network for common acute asthma management?
- avoid allergens
- smoking cessation
- inhaled therapy personalised asthma plan (PAP)
- regular review of PAP
When consulting the stepwise guidelines to asthma management, what is generally the first treatment option?
- low dose of inhaled corticosteroids
If a patient does not respond to treatment, is it best to increase the dosage or the current treatment such as inhaled corticosteroids?
- no - better to add another medication such as B2 agonist
What is a preventer in the treatment of asthma and COPD?
- inhaler to ⬇️ inflammation - blocks inflammation pathway
If inhaled corticosteroids fails as the first line of treatment, what preventer would generally be recommended to combine with the inhaled corticosteroids?
- long lasting B2 agonist - Salmeterol (long lasting B2 agonist)
What is a reliever in the treatment of asthma and COPD?
- used to treat acute exacerbations - inhaler to ⬆️ bronchodilation
When should a reliever inhaler in the treatment of asthma and COPD be used?
- when symptoms are exacerbated
When should a preventer inhaler in the treatment of asthma and COPD be used?
- every day - regardless of symptoms
What drug is used most commonly as a reliever?
- short acting B2 agonists - Salbutamol
Why is a personalised action plan for asthma important?
- ⬆️ asthma control - ⬇️ emergency contact with GP - ⬇️ hospital administrations
What should be included in the annual check up with the GP about a patients asthma plan?
- number of exacerbations - review of medication - compliance to medication - spirometry
If a patients symptoms decline or their asthma management is poor, where would a GP refer the patient to?
- secondary care specialist
If a patient with asthma had an exacerbation and attended A+E what would be the first examination the medics would do?
- assess pulse oximetry - SaO2 >92%
If a patient with asthma has an exacerbation and attends A+E with a PaO2 <92%, what would be the first examination the medics would do?
- check arterial blood gas - life threatening asthma
What sort of scan is routinely carried out in patients with respiratory symptoms?
- Chest X-ray
If possible to attain, what 2 respiratory measures would be useful?
- PEF - FEV1
If a patient with asthma had an exacerbation and attended A+E what would be the first line of treatment the medics would administer?
- high dose using a nebuliser - B2 agonist (salbutamol) + M3 inhibitor (ipratropium bromide)
If a patient with asthma had an exacerbation and attended A+E a steroid may be given. Would this be through an inhaler or orally/intravenously?
- orally or intravenously - provides systemic effect
If a patient with asthma had an exacerbation and attended A+E a steroid may be given. What steroid would be given intravenously?
- hydrocortisone
If a patient with asthma had an exacerbation and attended A+E a steroid may be given. What steroid would be given orally?
- prednisolone
If a patient with asthma attended A+E with a severe asthma attack what mineral could be given intravenously?
- magnesium
Why is magnesium given in severe asthma attacks?
- bronchodilator
- stabilises T cells
- ⬇️ inflammation
Can aminophylline be given intravenously in acute asthma?
- yes - acts a bronchodilator
How long should a patient be on the medication they will continue to take once discharged, prior to being discharged?
- 24 hours
Prior to being discharged from hospital after an acute asthma attack, what should the patients PEF1 be?
- >75% of best or predicted
Prior to being discharged from hospital after an acute asthma attack, what should the patients diurnal variability be?
- <25%
Prior to being discharged from hospital, what must the patient be checked and advised for, which are similiar to the British Thoracic Soceity guidelines?
- check inhaler technique
- personalised asthma plan is understood
- smoking cessation (support and guidance)
- ⬇️ oral steroid dose slowly
- review with doctor/nurse in 2 weeks
In COPD, do patients lung function improve or gradually decline?
- progressively decline
Is COPD reversible?
- largely irreversible
Is type 1 or 2 respiratory failure likely in patients with COPD?
- type 2 respiratory failure
What is cor pulmonale?
- right heart failure caused by respiratory disease
- COPD patients are at risk of this
What are some simple lifestyle advice that patients with COPD should recieve?
- smoking cessation - ⬆️ activity - improved nutrition
In COPD what are the normal pharmacological management plans?
- inhaler therapy
- manage exacerbations
- long term O2 therapy
- non-invasive ventilation
In extreme cases what treatment could patients with COPD have?
- lung transplant - lung resection
In COPD what are the normal non pharmacological management plans?
- pulmonary rehabilitation - counselling - palliative care
In COPD what pharmaceuticals do patients take to manage their symptoms?
- short acting B2 agonist
In COPD what combinations of pharmaceuticals do patients take?
- ICS + LABA + LAMA
In COPD why are they administered with Theophylline?
- bronchodilator - given orally
Why are COPD patients given a carbocisteine?
- mucolytic drug - helps thin mucus and open airways
If patients with COPD have an acute exacerbation, what are the common pharmacological management options?
- nebulised short acting B2 agonist
- systemic steroids
- controlled O2
- intravenous aminophylline
- non invasive ventilation
- antibiotics
What improves survival in COPD?
- long term O2 therapy - non invasive ventilation - lung volume reduction therapy
What are some basic points to consider when discharging a COPD patient?
- nutrition - smoking cessation - appropriate inhaler and correct technique - pulmonary rehabilitation - palliative care - vaccinations - psychological support
