Asthma & COPD Flashcards
Asthma: Pathophysiology
- Chronic inflammatory disorder of airways
- Recurrent episodes of wheezing, breathlessness, and chest tightness
- Airflow obstruction is reversible
Asthma: Classifications
Classifications:
- Mild persistent, moderate persistent, and severe persistent
Slightly differing definitions for adults and children
Asthma: Goals of Therapy
Reduce impairment
- Prevent chronic symptoms
- Reduce use of inhaled short-acting beta agonists
- Maintain normal or near-normal pulmonary function
- Maintain normal activity levels
- Meet patient/family expectations of asthma care
Reduce risk
- Prevent recurrent exacerbations & minimize ER visits & hospitalizations
- Prevent loss of lung function
- Provide optimal therapy with minimal ADRs
Asthma Step Therapy
- First, determine severity of asthma symptoms
- Go to Step Therapy Chart, and start at recommended step
- The GINA Guidelines prefer an aggressive approach to gaining quick control
- Assess patient’s response ever 2-3 months
Asthma- Mild: Pharmacodynamics
- Use step 1 therapy
- Use short-acting beta2 agonists, as needed, for symptoms
- Patients have symptoms when exposed to triggers (upper respiratory infections, allergens, chemical inhalants)
- Exercise can be mild intermittent
- Patients need an annual flu shot
Asthma- Mild: Treatment
Treat with low dose inhaled corticosteroid medication daily
- Low dose inhaled corticosteroids are the mainstay for patients of all ages
Use beta agonists as needed; if using 2 days or more per week, then step up therapy
Asthma- Moderate: Treatment
Treat with medium-dose inhaled corticosteroids
- or low-dose inhaled steroids plus leukotriene receptor modifier
Short-acting beta agonists may be used
Exacerbations may require oral corticosteroids
Asthma- Severe Persistent Asthma: Treatment
Step 4 therapy
- Medium-dose inhaled corticosteroids plus long-acting beta agonist
- Or medium-dose inhaled corticosteroid and a leukotriene modifier or theophylline
Step 5 therapy
- High-dose inhaled corticosteroids plus long-acting beta agonists
Step 6 therapy
- High-dose inhaled corticosteroids plus long-acting beta agonists and oral corticosteroids
Requires consultation with asthma specialist
Asthma: Monitoring
Once control is achieved, the patient is seen every 2-3 months to determine if a step-up or -down in therapy is indicated
The GINA Guidelines recommend that the dose of inhaled corticosteroids be reduced about 25-50% every 2-3 months to the lowest possible dose to maintain control
Asthma: Managing Exacerbations
Treat with oral steroids to regain control
Use a short burst
- Adults: 40-60 mg/day for up to 5-10 days
- Children: 1-2 mg/kg/day (max 50 mg/day) for 3-10 days
If not effective, then step up therapy
Asthma: Home Management
Assessing severity
- Risk factors for fatal asthma attack include: previous severe exacerbations requiring intubation or ICU admission, 2 or more hospitalizations or 3 ED visits in the past year, use of more than 2 short acting beta agonist inhalers per month, worsening asthma, low socioeconomic status
In-home Treatment
- Increased use of inhaled beta agonist (2-6 puffs every 20 minutes)
- Oral corticosteroiuds
- Good response: stepped up therapy for several days
Asthma: Pregnant Patients
Monitor asthma symptoms at each prenatal visit
Inhaled beta agonists are the drug of choice
Inhaled corticosteroids are the long-term drug of choice
Asthma: Pediatric Patients
Three categories of wheezing in children younger than age 5 years
- Transient early wheezing
- Persistent early-onset wheezing
- Late-onset wheezing/asthma
The GINA Guidelines have treatment categories for 0-5 years & 5-11 years
Stepwise approach is similar in adults and children but not the same
- Some medications are not approved or should not be used in children
- Long-acting beta agonists should not be prescribed singly but need to be combined with an inhaled corticosteroid
Asthma: Challenges in Pediatrics
Delivering medication to children
- Use aerochamber with mask for infants and young children
- Use spacer for all children
- Home nebulizer is an option
School-age and adolescent children: need to use inhalers at school
- Need education & observation of self-administration
- Will need note to school about use of medication at school
- Asthma action plan provided to school nurse
Asthma: Older Adults
Determine if symptoms are reversible (asthma) or not (possibly COPD)
Medications
- Increased ADRs
- Interactions with medications taken for chronic medical conditions (beta blockers)
Asthma: Special Situations
Seasonal Allergies
- Start long-term control medications more than 1 month before allergy season starts
Cough variant asthma
- Trial of bronchodilator
- Same stepwise management
Exercise Induced Asthma (EIA)
- Most asthmatics have EIA
Asthma: Treatment for EIA
- Short acting beta agonist 15 minutes before exercise (2 to 3 hours)
- Salmeterol lasts 10-12 hours (cannot use if using as long-term care medication)
- Mask or scarf over mouth if EIA is cold-induced
- Leukotriene modifier may help
Asthma: Monitoring
The GINA Guidelines recommend ongoing monitoring of the following six areas:
- Signs and symptoms
- Pulmonary function
- Quality of life and functional status
- History of asthma exacerbations, pharmacotherapy
- Patient-provider communication
- Patient Satisfaction
Asthma: Outcome Evaluation
Optimal outcome is being able to do activities of daily living with minimal asthma symptoms
Refer to an asthma specialist:
- If there is difficulty achieving or maintaining control
- If immunosuppressive therapy is being considered
- Any adult who requires step 4 therapy or child who requires step 3 therapy
Asthma: Patient Education
Written asthma action plan include:
- Overall treatment plan
- Specific drug therapy
- Drugs as part of treatment regimen
- Adherence issues
Review asthma action plan routinely, at least every 6 months
COPD: Definition and Risk Factors
Definition:
- Condition of chronic airflow limitation
- Progressive and heterogeneous
- Involves airways and lung parenchyma
Risk Factors:
- Smoking
- Occupational exposure
COPD: Diagnosis and Classifications
Diagnosis
- Spirometry Tests: positive when forced expiratory volume in 1 second (FEV1) & forced vital capacity (FVC) is less than 70%
Classifications:
- Mild, moderate, severe, very severe
COPD vs. Emphysema
Patients with COPD
- Are obese
- Are diagnoses as chronic with copious sputum production
- Suffer from hypoxemia, cyanosis, & carbon dioxide retention
Patient with Emphysema
- Are older and thinner at diagnosis
- Are barrel chested and breathe through pursed lips
- Suffer from dyspnea
COPD: Pathophysiology
Acute and chronic inflammation
Cellular proliferation changes
Environmental triggers implicated in immune response
COPD: Manifestations
Emphysema
- Closely linked to cigarette smoking
- Structural changes are the same in smokers
Chronic Bronchitis
- Closely linked to cigarette smoking and other inhaled irritants
COPD: Suggested Therapies
Bronchodilators, Corticosteroids, O2, antibiotics, Leukotrienes, Alpha-trypsin augmentation therapy, immunizations, Smoking cessation
COPD Therapies: Bronchodilators
Beta agonists
- Short acting vs long acting vs ultra-long acting
Methalyxanthin
- Selective Phosphodiesterase (PDE)
Muscarinic Agents
- Reduce exacerbations and hospitalizations
COPD Therapies: Corticosteroids
Inhaled
- Work as both monotherapy & in combination with inhaled bronchodilators
Oral
- Work for short-term treatment as they shorten recovery time, improve lung function, & decrease hypoxemia
PDE-4 Inhibitors
- Create bronchial relaxation and decrease activation of the immune response
COPD Therapies: Oxygen
Used short term during acute exacerbations
Used long term in chronically hypoxemic patients
Should be saturated to greater than 90%
Improves exercise tolerance, neuropsychological functions, and quality of life
COPD Therapies: Antibiotics
Based on local resistance patterns
Amoxicillin/clavulanic acid
Tetracycline
Macrolide antibiotics
Second line: respiratory fluoroquinolones
COPD Therapies: Leukotrienes & Alpha-Trypsin Augmentation
Leukotrienes
- No data to support use in COPD
Alpha-trypsin augmentation
- Used in patients with emphysema related to genetic alpha1 antitrypsin deficiency
- Not used in patients with alpha1 antitrypsin deficiency
COPD Therapies: Immunizations
Influenza Vaccine
- Should be administered annually between October and January
Pneumococcal Vaccine
- Should be administered every 6 years regardless of age
COPD Therapies: Smoking Cessation
Patients with COPD must stop smoking
Smoking cessation benefits include ventilatory function returning to a nearly normal age-related rate
COPD: Monitoring
Signs and symptoms
Pulmonary function
Pharmacotherapy
Quality of life
COPD Monitoring: Signs and Symptoms
Monitor sputum for color changes
Report any symptoms of respiratory infection
Remain indoors, and report signs of respiratory distress during times of poor outdoor air quality
Use bronchodilators or oxygen
COPD: Pharmacotherapy
- Patients should bring medications on every visit to provider
- Assess amount of beta2 agonists
- Assess use of inhaled bronchodilators
- Assess changes in respiratory therapy
- Review written medication management plan
COPD Monitoring: Quality of Life
Assess tolerance of activities of daily living
Assess tolerance to exercise, activity level, and nutrition
Assess financial burden of illness
COPD: Patient Education
Discuss treatment plan and drug therapy
Discuss reasons for taking the drug and drugs as part of the total treatment plan, and adherence issues
Focus on maintaining optimal pulmonary function and quality of life
Teach self-management
