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Clinical Medicine PA 581: Pulmonary > Asthma/COPD > Flashcards

Asthma/COPD Flashcards

objectives

1
Q

Asthma Pathophys

A
  • Smooth muscle dysfunction
  • Airway inflammation
  • Airway remodeling
    • Fixed in a narrow position from collagen deposition
    • Glands hypertrophied
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2
Q

Asthma pathophys: smooth muscle dysfxn

A
  • exaggerated contraction
  • increased smooth m. mass
  • increased release of inflammatory mediators
  • bronchoconstriction
  • bronchial hyper-reactivity
  • hyperplasia/hypertrophy
  • inflmmatory mediator release
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3
Q

Asthma pathophys: Airway inflammation

A
  • inflammatory cell infiltration/activation
  • mucosal edema
  • cellular proliferation
  • epithelial damage
  • basement membrane thickening
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4
Q

Asthma pathophys: Airway remodeling

A
  • Cellular proliferation
    • smooth m cells
    • mucous glands
  • inc matrix protein deposition
  • basement membrane thickening
  • angiogenesis
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5
Q

Asthma Phases

A
  • acute response
  • chronic/infammatory response
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6
Q

Asthma pathophys: acute response

A
  • Bronchial hyperreacticity
  • Mucosal edema
  • Airway secretions
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7
Q

Asthma pathophys: chronic/inflammatory response

A
  • Increase in inflammatory cell number
    • LOTS of cells can release inflammatory medicators
    • Steroids will control this
  • Can lead to epithelial damage
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8
Q

Pathologic features associated with asthma

A
  • Variable airflow obstruction
  • Bronchoconstriction
  • Edema
  • Cough
  • Airway hyperreactivity
  • Airway inflammation (Eosinophils, mast cells, lymphocytes, neutrophils)
  • Mucous hypersecretion
    • Goblet cell metaplasia
    • Submucosal gland hypertrophy
  • Impaired mucous clearance
  • Smooth muscle hypertrophy/hyperplasia
  • Subepithelial matrix protein deposition
  • Collagen deposition
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9
Q

asthma definition

A
  • Inflammatory d/o of airways
  • Reversible airflow obstruction
  • Hyper-responsiveness
  • Often viewed as atopic, allergic d/o with altered T cell function
  • Best to view it as BOTH inflammatory AND smooth muscle d/o
    • Variable severity and reversibility
    • Tx should addres BOTH of these
    • FH important!
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10
Q

asthma etiology

A
  • Multifactorial
    • Genetic
      • FH of rhinitis, urticaria, eczema
    • Viral infections
      • Viral URI is the #1 cause of exacerbation = asthma attack
    • Environmental
      • Allergic: Pollen, molds, animal dander, dust mite
      • Non-allergic: tobacco, chemicals, perfumes, cold, temp changes, pollution
    • Others
      • Drugs (BB and NSAID)
      • GERD
      • Rhinitis/sinusitis
      • Food (rarely)
      • Stress (more in adults)
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11
Q

other asthma facts

A
  • Asthma is MC chronic childhood illness in US
  • Increase in prevalence in 15 yrs by 58% overall
  • 24million people have asthma (includes 7million children)
  • Hospitalizations d/t asthma are preventable or avoidable with proper primary care
    • Undertreatment and inappropriate therapy are the major contributors to asthma morbidity and mortality
    • Underdiagnosed and treated, esp in children
    • Over 500,000 hospitalizations/yr
    • Over 6,000 deaths/yr
  • Asthma is the third leading cause of preventable hospitalizations in US
    • >100million days of decreased activity, 10million of lost school/ year
  • 75% of those with asthma have persistent asthma and require daily controller med (far less receive these)
  • Patients OVERESTIMATE the control of their asthma
    • We need to tell them they should not be having symptoms
    • Asthma mortality NOT directly related to severity
      • d/t variability of asthma
      • people with “mild” asthma may have SAME SEVERITY, just less often
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12
Q

asthma epidemiology

A
  • 43% male; 57% female
  • 67% at 18+; 33% 0-17 y/o
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13
Q

Ddx for children w/ asthma

A
  • Allergic rhinitis and sinusitis
  • Vocal cord dysfunction
  • Vascular rings
  • Laryngotracheomalacia
  • Tumor or enlarged lymph nodes
  • Viral bronchiolitis
  • Cystic Fibrosis
  • Bronchopulmonary dysplasia
  • Aspiration due to gastroesophageal reflux
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14
Q

Ddx for adults w/ asthma

A
  • Chronic obstructive pulmonary disease
  • Congestive heart failure
  • Pulmonary Embolism
  • Mechanical obstruction (benign or malignant tumors)
  • Pulmonary infiltration with eosinophilia
  • Cough secondary to drugs (ACE inhibitors)
  • Laryngeal dysfunction
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15
Q

Dx of asthma: important points

A
  • Children with asthma are often mislabeled (bronchitis, bronchiolitis, croup, pneumonia) and may not get adequate therapy
    • DX NOT NEEDED TO CONSIDER AND BEGIN TREATING ASTHMA SX!!
    • Viral URI are MC precipitant of wheezing and cough in kids- do NOT preclude the dx of asthma= it is possible to have asthma and have it triggered by a viral illness!
  • Recurrent episodes of cough and wheeze are almost always d/t asthma in both adults and kids
  • Cough can be sole sx
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16
Q

asthma medical hx

A
  • Episodic wheeze
  • Chest tightness
  • SOB
  • Cough
  • Sx worsen in presence of aeroallergens, irritants or exercise
  • Sx occur or worsen at night, awakening pt
    • Because you have a surge of cortisol in am naturally, then use it all day (little left at night)
  • Pt has h/o allergic rhinitis or atopic dermatitis
  • FH of asthma, allergy, sinusitis or rhinitis
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17
Q

4 stages of asthma

A
  • Stage 1: Intermittent
  • Stage 2: Mild Persistent
  • Stage 3: Moderate Persistent
  • Stage 4: Severe Persistent
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18
Q

4 stages of asthma–> Stage 1: Intermittent

A
  • Symptoms less than a week
  • Brief exacerbations
  • Nocturnal symptoms not more than twice a month
  • FEV1 or PEF ≥ 80% predicted
  • PEF or FEV1 variability <20%
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19
Q

4 stages of asthma–> Stage 2: Mild Persistent

A
  • Symptoms more than once a week- but less than once a day
  • Exacerbations may effect activity and sleep
  • Nocturnal symptoms more than twice a month
  • FEV1 or PEF ≥ 80% predicted
  • PEF or FEV1 variability 20-30%
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20
Q

4 stages of asthma–> Stage 3: Moderate Persistent

A
  • Symptoms daily
  • Exacerbations may affect activity and sleep
  • Nocturnal symptoms more than once a week
  • Daily use of short-acting beta-2 agonist
  • FEV1 or PEF 60-80% predicted
  • PEF or FEV1 variability >30%
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21
Q

4 stages of asthma–> Stage 4: Severe Persistent

A
  • Symptoms daily
  • Frequent exacerbations
  • Frequent nocturnal asthma symptoms
  • Limitation of physical activities
  • FEV1 or PEF ≤60% predicted
  • PEF or FEV1 variability >30%
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22
Q

asthma clinical sx

A
  • Noisy/musical breath sounds
  • Nocturnal awakenings
  • Exertional dyspnea and “air hunder”
  • Cough, SOB, wheeze
  • Nasal flaring and grunting
  • Suprasternal, intercostal and subcostal retractions
  • Pallor, duskiness and cyanosis
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23
Q

Physical findings that increase probability of asthma

A
  • Thoracic hyper-expansion on CXR
  • Sounds of wheezing during normal breathing or a prolonged expiratory phase
  • Increased nasal secretions, mucosal swelling, sinusitis, rhinitis or nasal polyps
  • Atopic dermatitis, eczema
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24
Q

Therapeutic response that can strengthen dx of asthma

A
  • Clinical improvement following bronchodilator and/or steroids
  • So… when you don’t know but it sounds like asthma, give a bronchodilator and see if it helps sx
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25
Q

Making the Dx of asthma

A
  • Recurrent sx
  • Risk factors known
  • Response to drug (bronchodilator or steroids)
  • Other etiologies ruled out
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26
Q

goal of asthma tx

A
  • Prevent chronic asthma sx and exacerbations in day and nigh
  • Maintain normal activity; no limitations
  • Have normal/near-normal lung fxn
  • Prevent acute episodes
  • Reduce ED visits and hospitalizations
  • Have minimal SE on tx
  • Enhanced adherance (simple meds)
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27
Q

Stepwise approach to managing asthma

A
  • Gain control
  • Maintain control
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28
Q

Gain control

A
  • Preferred approach is to start therapy with more intensive program
    • Suppresses airway inflammation and gain prompt control of reversible obstruction
    • Ex: burst therapy steroids
  • To do this, you need to define the severity of asthma
  • Intervene with optimal medications
  • Normalize activities, lung function and lifestyles
  • Then try to “step down” tx to optimal levels
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29
Q

Maintain control

A
  • f/u q 1-6 mos (usually q3-4)
  • PFTs >=2x/yr
  • “step down” long term control meds to achieve optimal control as safely and effectively as possible
  • Keep it- Simple, Safe, Effective
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30
Q

Asthma tx

A
  • No matter what ICS is ALWAYS in the treatment regime for persistent asthma
  • Pts are candidates of Mainstay Therapy if the “RULES OF TWO” apply
    • They are using a quick-relief inhaler >2x/wk
    • They awaken d/t asthma >2x/month
    • They refill their quick-relief inhaler Rx >2x/year
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31
Q

Where are the targets of asthma therapy?

A
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32
Q

current tx modalities of asthma

A
  • Acute Tx or “Rescue” Therapies
  • Chronic “controller” therapies​
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33
Q

Acute Tx or “Rescue” Therapies

A
  • Inhaled short acting β2 agonists (SABA) (Albuterol, Xopenex®)
  • Systemic (injected) β2 agonists (epinephrine, terbutaline)
  • Anticholinergics (Ipratropium bromide – Atrovent)
  • Systemic steroids (Prednisone; PO preferred)
    • 100% bioavailable; drug goes everywhere (not just lungs!)
  • Oxygen, hospitalization, ventilation
34
Q

Chronic “Controller” Therapies

A
  • Inhaled corticosteroids (Flovent®, Pumicort©, Qvar®, Asthmanex®)
    • Only about 2% is absorbed systemically (most goes directly to lungs)
  • Long-acting bronchodilators (LABA) (Serevent®, Foradil®)
    • NEVER use as monotherapy!
  • Mast cell stabilizers (Intal®): not used often
  • Leukotriene modifiers (Singulair®): good add-on therapy
  • Combination therapies (Advair®, Symbicort®, Dulera®)
35
Q

Asthma Medications

A
  • Long-term controller asthma meds are taken daily to achieve and maintain control of persistent asthma sx
    • Most effective long-term maintenance meds reduce inflammation!
      • Inhaled steroids are best for persistent asthmatics
      • ICS = First-line maintenance therapy for ALL persistent asthma, even mild
    • Other classes of controller drugs, such as the LTM’s can be used, but they have limitations!
36
Q

Inhaled Corticosteroids (ICS)

A
  • ICS can decrease airway inflammation and bronchoconstriction of smooth muscle in mild to moderate asthmatics.
  • Earlier tx with ICS appears to prevent pts from developing more prominent chronic lung changes and airway obstruction
    • Long term use (> 2 yrs) significantly improves lung fxn
    • Safe to use
37
Q

Daily use of ICS can

A
  • Diminish asthma sx; improvement will continue gradually
  • decreases occurrence of severe exacerbations
  • decreases use of quick-relief meds
  • Improved lung fxn (PEF, FEV1, & airway hyperresponsiveness)
38
Q

Effects of ICS on Inflammation

A
  • Inhibits inflammatory mediator cells (decreases airway edema)
  • Can reverse effects of airway remodeling
39
Q

Long-Acting b2-Agonists (LABA)

A
  • Safe and effective, easy to use, quick onset of action, well-tolerated
  • Enhance benefits of ICS & more effective than ↑ ICS
  • Treats nocturnal cough & exercise-induced bronchoconstriction for up to 12-14 hrs after use
  • Enhance adherence and improve lung fxn
  • NOT TO BE USED AS MONOTHERAPY!
40
Q

Combination Therapies (ICS + LABA)

A
  • Serevent® and Flovent® are available together in a DPI (Diskus® ) as Advair®(100/50, 250/50, 500/50)
  • Clinical efficacy of a LABA & ICS is due to complementary actions of these two classes of drugs
    • Treats BOTH inflammation and bronchoconstriction in a single device = IDEAL

Leukotriene Modifiers (LTM)

  • Class of agents used in asthma therpay BUT limited long-term data exists
    • Best used as add-on therapy, esp. for stuffiness and persistent cough
    • Easy to dose, lack of perceived “steroid side effects”

Play a role in initial asthma tx, however, only a fraction of people treated with these agents appear to respond to therapy and they tend to have milder and more intermittent disease

41
Q

asthma medical therapies

A
  • Overall, short-acting bronchodilators account for over 50% of all asthma Rx among children and adults.
    • Despite that asthma is now recognized as a chronic inflammatory disorder
  • In Georgia, less than half of all asthmatics who need daily “controller” meds actually have them prescribed.
42
Q

measuring effectiveness of asthma tx

A
  • Improvement in lung fxn tests or PFT’s (spirometry: FEV1 > 6% or FEF25-75 > 35%)
  • Improved AM/PM Peak Expiratory Flow
    • Using Peak Flow Meters (measure speed & amt of air expelled in single puff)
  • decrease use of “rescue” drugs (200 puffs per canister)
    • Shouldn’t be using more than 4 canisters annually!
  • decrease daytime and exercise-related resp. sx
  • decrease nocturnal awakenings/cough
  • Improved “quality of life”
43
Q

Metered Dose Inhalers (MDI)

A
  • MDI’s are mainstay for most asthma controller meds prescribed in US
    • Small, portable, efficient, quick, & inexpensive to use (and lose!)
  • When used with a spacer device, MDI’s deposit particles in small airways as effectively as nebs
    • Effectively used at any age
    • Technique is CRITICAL! Require SLOW INSPIRATORY flow rates
44
Q

Typical MDIs

A
  • Asthma spacers
  • Dry Powder Inhalers (DPI’s)
  • Diskus
45
Q

Dry Powder Inhalers (DPI’s)

A
  • Improved ease of use
  • Impact of impending CFC phase-out
  • decrease volume of inhaled powder
  • Dose counters/indicators
  • ↑ dose capacity in devices
  • No dose to dose variation
46
Q

Diskus®

A
  • Open: Expose level underneath device
  • Click: Push lever away until you hear or feel a click
  • Inhale: Exhale, then bring device to lips and breathe in steadily & deeply thru inhaler. Airflow thru device ensures that dose is inhaled
  • Close Diskus
47
Q

Is My Asthma Well-Controlled?

A
  • Have I visited the ER or hospital in past year?
  • Do I use my rescue-inhaler more than 2x/wk?
  • Have I found myself coughing or breathless in AMs and/or PMs?
  • Do I limit my activities or miss work/school?
  • Have I received Rx for oral prednisone >1x in past year?
48
Q

COPD

A
  • Chronic Obstructive Lung Disease
  • Progressive airway obstruction
  • Associated with smoking 90% of COPDers have smoked
  • Not reversible
  • Combination of chronic bronchitis, small airway obstruction and emphysema
49
Q

COPD caused by

A
  • Cigarette smoke (centrilobar emphysema)
  • Alpha-1- antitrypsin deficiency (panacinar emphysema)
  • Recurrent Airway infections
50
Q

COPD incidence and mortality

A
  • Approx 5% of Americans have COPD for a total of ≈12 million
  • 125k deaths from COPD in ‘97
51
Q

COPD symptoms in pt (esp over 40 y/o)

A
  • Straw experiment
    • How does it feel to take so long to breathe out?
  • Shortness of breath, especially with exertion, resulting from being unable to expire completely…worsening over time
    • This is worsened with exercise/exertion because patients are breathing faster​
  • Chronic, productive (especially in the morning) cough (can be a dry cough)
  • Wheezing…patients will tell you this
  • Chest tightness/heaviness
  • Recurrent acute bronchitis
  • Air hunger/increased effort to breathe
  • Symptoms can happen late; after 50% of lung function is lost
52
Q

COPD signs

A
  • Hypoxemia
  • Tachypnea
  • Dyspnea on exertion
  • Barrel chest/increased AP diameter
  • Air trapping, widened rib spaces on CXR
  • Wheezing (worse in exacerbation)
  • Nail clubbing
  • Peripheral edema (often later stage)- RHF
  • Hypercapnea (later stage)
53
Q

COPD spirometery

A
  • Normal lung function (FEV1) declines by 30 ml per year after the age of 30
  • In COPD- declines by 100ml per year
54
Q

COPD risk factors

A
  • Smoking
  • Air pollution
  • Occupational exposure
  • Allergies
  • Hereditary/Genetics
55
Q

COPD mortality rate

A
  • FEV1, BMI, Dyspnea, 6 minute walk (6MW) used as prognostic factors
    • FEV1 = 1 Liter is 4 year prognosis
    • End Stage COPD is approx. 1 year survival
    • Oxygen
    • Medicines
56
Q

COPD Pathophys

A
  • Combination of Chronic Bronchitis and Emphysema
  • Narrowing of airway lumens and thickened walls
57
Q

Chronic Bronchitis

A
  • Clinical diagnosis
  • Chronic cough and sputum production for at least 3 months of the year for at least 2 years.
  • In the absence of any other disease.
  • Caused by hypertrophy and hyperplasia of mucus secreting glands
  • Intermittent dyspnea, copious sputum
58
Q

Emphysema

A
  • Morphologic Diagnosis
  • Enlargement of airspaces distal to the conducting airways
    • Bronchioles and alveoli walls are weakened
    • Lysis of elastin and structural proteins
  • Types
    • Centrilobular- from smoking
    • Panacinar- alpha 1 def
59
Q

Centrilobular Emphysema

A
  • Involves the Bronchioles
    • With normal distal alveoli (except in severe dz)
  • Exclusively found in smokers
  • Central airway obstruction
  • Upper lobe predominant
    • Lung volume reduction surgery
60
Q

Panacinar Emphysema

A
  • Alpha-1 antitrypsin deficiency
    • Genetic disease
    • Patients have severe disease when compared to age/pack history
  • Exacerbated by smoking
  • Lower Lobe predominant
61
Q

Pink Puffer = Emphysema

A
  • Onset > age 50
  • Dyspnea progressive, severe, constant
  • Cough and sputum production mild, absent
  • Weight loss
  • Body habitus is thin, cachexia
  • AP diameter increased/ barrel chest
  • Percussion hyperresonant
  • Auscultation diminished
  • CXR- bulla, blebs, hyperinflation, hemidiaphragms are flattened
  • Labs: EKG normal, ABG without hypercapnia or hypoxemia
  • PFTs: increased TLC, increased RV, decreased diffusion capacity
62
Q

Blue Bloater = Chronic Bronchitis

A
  • Onset = after age 35
  • Dyspnea is intermittent, mild to moderate
  • Cough and sputum production persistent and severe
  • No weight loss, can be obese, s/sx of RHF
  • No increase in AP diameter
  • Percussion normal
  • Auscultation = wheezing, rhonchi
  • PFTS: normal DLCO and RV/TLC
  • CXR = Cardiomegaly, increased lung markings
  • Labs – EKG with Rt Ventricular Hypertrophy, rt. Axis deviation
  • Hypoxemia and hypercapnia are moderate to severe, resp acidosis
63
Q

Ddx COPD

A
  • CHF
  • Chronic asthma
  • Pulmonary embolism
  • Bronchial asthma
  • Bronchiectasis
  • Cystic Fibrosis
  • Central Airway obstruction
  • Pulmonary Fibrosis
64
Q

GOLD guideline criteria for COPD

A
  • Stage 0: At Risk
  • Stage I: Mild
  • Stage II: Moderate
  • Stage III: Severe
  • Stage IV: Very Severe
65
Q

GOLD guideline criteria for COPD: Stage 0

A

Stage 0: At Risk

  • Chronic s/sx
    • Exposure to risk factors
    • Normal PFTs
    • Treatment- influenza vac, avoid risk factors
66
Q

GOLD guideline criteria for COPD: Stage I

A
  • Stage I: Mild
    • FEV1/FVC < 70%
    • FEV1 >/= 80%
    • With or without s/sx
    • Treatment:
      • Avoid risk factors
      • Influenza vac.
      • SABA prn
67
Q

GOLD guideline criteria for COPD: Stage II

A
  • Stage II: Moderate
    • FEV1/FVC < 70%
    • FEV1 btw 80 -50%
    • With or without s/sx
    • Treatment:
      • Avoid risk factors, influenza vac.
      • SABA prn
      • Long acting Bronchodilator

Pulmonary Rehab

68
Q

GOLD guideline criteria for COPD: Stage III

A
  • Stage III: Severe
    • FEV1/FVC < 70%
    • FEV1 btw. 50- 30 %
    • With or without s/sx
    • Treatment:
      • Avoid risk factors, influenza vac.
      • SABA prn
      • Long acting bronchodilator
      • Pulmonary rehab
      • ICS – if repeated exacerbations
      • Evaluate for oxygen
      • Daliresp (Roflumilast)
69
Q

GOLD guideline criteria for COPD: Stage IV

A
  • Stage IV: Very Severe
    • FEV1/FVC < 70%
    • FEV1< 30% or <50% with chronic respiratory failure
    • Treatment:
      • Avoid risk factors, influenza vac.
      • SABA
      • Long acting Bronchodilator
      • Pulmonary rehab
      • ICS
      • O2
      • ? Surgical candidate for lung volume reduction surgery.
      • Consider hospice
70
Q

COPD Tx w/ meds

A
  • SABA
    • Albuterol
      • ProAir, Proventil 1-2 puff q4h prn
    • Levalbuterol
      • Xopenex 2 puffs TID prn
  • Long Acting Bronchodilators
    • Tiotropium (spiriva)
      • 1 puff qd
    • Iprotropium bromide
      • neb solu q6-8 h
    • LABA: Salmeterol or formoterol
      • use BID
    • Theophylline
  • ICS
    • Beclomethasone
    • Budesonide
    • Fluticasone
  • Combination Inhalers
    • Advair
    • Symbicort
    • Dulera
  • Oral Corticosteroids
71
Q

COPD Dx work-up

A
  • Complete PFT’s with ABG
  • 6MW
  • CXR - ? CT scan of Chest
  • Alpha one antitrypsin level
  • EKG
  • ABG – resp. acidosis
  • CBC
  • BNP B-Type Natriuretic Peptide
  • Echo
72
Q

PFT for Obstructive COPD

A
  • decrease in FEV1, FVC, ratio
73
Q

PFT for hyperinflative COPD

A
  • increase in RV, TLC
74
Q

PFT for abnormal gas exchange COPD

A
  • decrease in DLCO
75
Q

COPD ABG

A
  • decrease PaO2, increase in PaCO2
76
Q

COPD clinical pearls

A
  • Methylxanthines
    • Theophylline
      • narrow therapeutic window
      • Cardiac sequelae if toxicities
      • Sometimes works, sometimes doesn’t
  • PO Albuterol is not safe from a cardiac standpoint (many COPD patients have concomitant cardiac disease)
  • Watch out for pneumothorax due to bullae; do a CXR with unexplained worsening dyspnea
  • In a young patient (age 40 or less) with COPD and a minimal or no smoking history, check an alpha-1 antitrypsin level…looking for a low level, indicating deficiency.
    • This is a genetic cause of COPD
  • Much higher incidence of COPD in HIV patients
  • Discuss code status with all COPD patients…IN THE OFFICE
77
Q

How to spot an acute exacerbation

A
  • From patient’s baseline:
    • Change in sputum color
    • Increase in shortness of breath
    • Increase in amount of sputum
  • Also look for signs of infection:
    • Fever, chills, hemoptysis, crackles/rales on lung exam
78
Q

COPD Exacerbation

A
  • CXR to rule out pneumonia as a cause for the exacerbation
  • Check oxygen saturation!
  • Decide whether or not to treat as an outpatient:
    • PO steroids (prednisone)/bronchodilators
    • PO Antibiotics
    • Close follow up
79
Q

COPD exacerbation Tx

A
  • Hospitalized (hypoxemic, very dyspneic, fever, weakness)
    • IV steroids, usually methylprednisolone, starting at 60mg IV Q6 hours, and taper…try not to dose less than Q8 hours for duration due to drug ½ life (transition to prednisone for discharge)
    • Scheduled nebs; if on tiotropium (anticholinergic) do NOT use ipratropium
  • When giving oxygen give only enough to get PaO2 above 60mmHg; this minimizes the danger of respiratory acidosis due to CO2 retention.
  • Levalbuterol (q6 hours) or albuterol (q4 hours) nebs
  • Mucolytic (guaifenesin) prn
  • Sputum cultures, usually give antibiotics, covering for S. pneumo, H. flu, M. cat.
    • Quinolones, cephalosporins, penicillins, macrolides
80
Q

COPD smoking cessation options

A
  • Nicotine replacement
  • Behavioral modification
  • Bupropion (Zyban, Wellbutrin)
  • Varenicline (Chantix)
81
Q

Smoking Cessation: other

A
  • Patients need you to initiate the conversation…EVERY VISIT
  • Medicare now reimburses for smoking cessation counseling
  • If you don’t attempt it, you are not doing your job
  • Bring them back for a smoking cessation visit
82
Q

COPDer

A
  • C: Corticosteroids (inhaled)
    • 20% decrease in Acute exacerbations, but can increase risk of pneumonia
  • O: Oxygen
  • P: Prevention (Flu/Pneumovax, tob cessation)
  • D: Dilators (Anticholinergic, SABA, LABA)
  • E: Experimental (LVRS = lung volume reduction surgery)
  • R: Rehabilitation

Clinical Medicine PA 581: Pulmonary (9 decks)

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