Asthma / COPD / Smoking Cessation Flashcards
What is the goal of Pulmonary function Tests
See how much air lungs will hold
how quick breathing is
What is IRV,VC, TLC,FRC, RV, ERV?
IRV- space to breathe in more
VC= Total air that can move in lung
TLC= Total air that can be in lung
FRC= volume of air that can still in after normal expiration
RV= air that is always in lung
ERV=max air exhaled below TV
What is FEV1?
Amount of air that can be expelled in 1 second
What is FVC?
Total volume air expired as rapid as possible
What is a high/normal FEV1/FVC ratio mean
Restrictive lung disease because hard to get air in so both values are low and may appear normal.
What does a low FEV1/FVC ratio mean
Obstructive lung disease because hard to get air out= FEV1 is low
What do we use spirometry tests for?
Diagnose lung disease
Measure extent- FEV1/FVC ratio
monitor progression
most accurate- compare to their normal
How do you run a spirometry test?
Tell patient to take deepest breath possible then exhale into sensor as hard as they can for at least 6 seconds.
Cons of spirometry tests.
Need full cooperation of patient
Do NOT use in:
people with risk of infection, high cranial and thoracic pressure= post surgery
What increase of FEV1 indicates bronchodilator response (asthma disease)
12%
What is a peak expiratory flow rate test do?
Portable meter to see forced expiration
What are cons of peak flow?
Need maximum effort for accuracy
proper technique
for self monitoring
What do we use Carbon Dioxide diffusing capacity for?
When we want to see the ability of diffusion of CO2 in alveoli
What is the pulse oximetry test?
Uses light absorptive of hemoglobin to determine oxygenation.
If you have issues with breathing what compensation will occur to balance pH
Metabolic/ kidneys will retain bicarbonate.
Which compensation mechanism is quicker respiratory or kidney?
Respiratory
How do you calculate Anionic Gap?
AG= Na- (Cl+HCO3)
What does it mean if you have high Anionic Gap?>11
Metabolic Acidosis
What is bronchoscopy?
Endoscoping the airways through mouth or nose
Determine Abnormality pH-7.1, PaCo2= 25, HCO3= 10
Due to the fact that pH is low it is acidosis, to determine if metabolic we see that HCO3 is low so it is metabolic PaCO2 is low only for compensatory
Determine abnormality, pH 7.32, PaCO2 51, HCO3=25 , PaO2= 70 and has cystic fibrosis.
Acidosis due to pH and respiratory due to compensatory HCO3 is normal because it takes days.
True of False: The majority of people with asthma have poor control.
True
True or false: When controlled Asthmatics have the exact same QoL and lifespan.
True
When in childhood which gender is more common with asthma and why?
males due to their airway being smaller
At what age is asthma in females more common?
greater than 40
What does atopy mean?
genetic predisposition for development of IgE which causes hyper-responsive airways
What is a long term complication of asthma if left untreated or poorly controlled?
remodelling which can become irreversible.
Which type of WBC is correlated with asthma?
eosinophils
What is the difference between Type 1 asthma and type 2?
Type 2- atopy= allergies and eosinophils
Type 1- obesity, smoke related
What FEV1/FVC will asthmatics have?
<75-80%
What two questions about difficulty of breathing should be asked in order to assess?
If it is occurring at night or is worse at night due to cortisol levels
if exercise makes it worse drop of FEV1 of >15%
True or false GERD can be correlated with Asthma
True
Which URTI are correlated with asthma?
Viral= RSV, influenza, rhinovirus
How does NSAIDS trigger asthma?
COX inhibition= more bronchoconstrict leukotrienes
What change to Expiration ratio would we see for asthmatics after bronchodilator?
> 12% increase (increase of 200ml)
What is the positive challenge test?
asses hyperactivity after doses of methacholine
asthmatics will respond to a greater degree
How often should a HCP monitor?
After diagnosis 3-6 months
after is 1-2 years
For diagnosis what is the different criteria for adult vs children
Adult= <0.75 and >12% increase (and 200ml)
Child= <0.8 and >12%
What lab tests can we do for asthmatics?
CBC
Eosinophil count
IgE []
What is the definition of asthma control? CTS
Daytime sx<2 days/week
Night sx<1/weak
SABA use <2 doses/week
Give me some example of endogenous stimuli of asthma.
GERD, stress, hormones, rhinitis
What is the mechanism of SABA?
peak in 5 minutes and selectively acts on B2 adrenergic receptors
What are the side effects of SABA? And why?
It can also act on B1 receptors= CVD side effects
tachycardia, tremor, insomnia, BP, BG, arrhythmias tachyphylaxis
What is the selectivity of salbutamol and terbutaline on B1?
1
What are are the DI of SABA?
Beta blockers= oppose action of SABA
diuretics that increase hypokalemia
TCA= increase s/e
QT prolongers
Give me the most common LABA’s
Salmeterol, formoterol, vilanterol and indacaterol
What is special about formoterol
quick onset, can be used as reliever
True or false SABA and LABAs have exact same MOA, S/E, and DI
True
What is the most effective treatment for asthma?
Steroids because DUHHHH ANTI INFLAMMATORY
What are the inhaled corticosteroids?
Fluticasone, budesonide, ciclesonide
What is special about budesonide?
Preffered product for pregnant women.
CARD JUST TO REMIND THAT IDK IF I WANT TO PUT SPECIFIC DOSING ON
What type of dose do we generally want for maintenance? DUH
Low dose
When starting out is it more effective to give moderate or low dose
moderate
Where is the line for the best benefit of fluticasone and budesonide?
200/d-fluticasone
400/d-budesonide
What is special about ciclesonide?
it is a prodrug and can reduce thrush s/e
General side effects of ICS?
harshness, irritation, cough, URTI, Thrush, growth retard (prob not),
True or false: Everyone should use a spacer
True- would make it more effective but usually only for kids or elderly.
Which corticoid is preferred for oral or IV when needed?
Oral= prednisone
IV= dexamethasone
When is oral corticoids used?
When severe asthma= may be long term
or acute distress= taper not needed.
What is the mechanism of action of LTRA?
stop leukotrienes from eosinophils to reduce inflammation
What are some side effects of LTRA’s?
headache, dizzy, depression, neuropsych effects
True or false: LTRAs are stronger than SABAs
FALSE
but if combo very good
What is our option for a LTRA
Montelukast
True or false LTRA’s are relievers
False they are controllers
What is the minimum age to get a LTRA
2 years old
What is dosing for montelukast?
2-5 years= 4mg QD hs
6-14 = 5mg QD hs
15+= 10 mg QD hs
At what age does their effect drop dramatically?
12 years old
What is LTRA’s role in care?
Alt to increasing ICS
no ICS wanted or used
Would Jeff Taylor be okay with combo medications of LABA and ICS?
Yes he would as it is more convenient and increases adherence
What is the only combo of LABA and ICS we should know
Symbicort (Budesonide and formoterol) as it can be used prn and daily
True or false theophylline is the most potent bronchodilator we have
False it is less effective than SABA
What is the use for theophylline?
add on BUT BAD SIDE EFFECTS= tachycardia, diarrhea, anorexia
What is MOA of theophylline?
inhibit PDE4= bronchodilator
What is MOA and age range for Omalizumab
> 6 if bad control on high ICS
Anti IgE antibody
When could we consider tiotropium(LAMA)?
add on for people >12 and severe uncontrolled asthma despite ICS/LABA
What is the role of macrolide in asthma?
can lower exacerbations in people >18 BUT bad ototoxicity and increasing resistance
True or false: Using SABA a lot is absolutely fine
Tricky question while nothing wrong medicinal wise, overuse of SABA can lower ICS usage = higher mortality, less control and more remodelling
True or false: using sedatives during an exacerbation is okay
False
What is the criteria to be high risk of exacerbation?
current smoker
> 2 inhalers a year
poor control per CTS
history
What is the base therapy for asthma ALWAYS?
SABA or bud/form PRN AND ICS
If we need to step up from base therapy what is our options?
if 1–11 years old= increase to medium dose ICS
>12 = add LABA
What is our option if the patient DOES NOT or CANNOT take a ICS?
LTRA
If base therapy was Symbicort PRN what is our step up?
Symbicort PRN and QD
After the first step up what is the next option if still not controlled?
6-11 years= add LABA OR LTRA
>12= Add LTRA and/or tiotropium
If high risk of exacerbation what should their base therapy be
Daily ICS and SABA prn
If in severe asthma territory what therapy is needed?
High dose of ICS and second controller (LAMA,LABA,LTRA) or systemic CS for 50% of the year
What do we do if high ICS and other controllers don’t help for severe asthma?
consider mabs, macrolides, anti-IL5
If asthma is uncontrolled what is the first thing you should do as a pharmacist?
Check use of inhaler
asses adherence
How often should pregnant asthmatic be reviewed?
4-6 weeks
When should we step down?
when >3 month control
If we step down what must we ensure with the patient?
See if they consent
choose a good time
have a plan inlace
HAVE ENOUGH DRUG TO GO BACK TO PREVIOUS DOSES
What Peak flow is considered green asthma control?
80-100%
What peak flow is considered yellow asthma control?
60-80%
What should patients do if in yellow control?
Increase medication to get back to green. if no improvement in 4 days go see doctor
What peak flow is considered red asthma control?
<60% USE RELIEVER AS MUCH AS NEEDED GO TO EMERGE
True or false: Interchanging Peak flow devices is recommended?
NO use one type so good accuracy and compare
How do we treat acute severe exacerbation
SABA/SAMA
CS= oral is able to breathe and eat, improve in 2 hours
O2= if <90
Mag IV=potent bronchodilator
intubate
What does IV magnesium do
potent bronchodilator
What is non drug treatment of exercise induced bronchocontriction?
scarf
fitness
Management of NSAID’s induced Asthma
LTRA
What do we give for pregnancy asthmatics?
Salbutamol or LABAs, Budesonide
LTRAs fine
Any changes to therapy for breastfeeding asthmatic?
All ok but prob not theophylline at high doses
What are the pros and Cons of MDI?
Pros=portable
Cons= prime, coordination, no dose counters
What are the steps for taking an MDI?
Shake, remove cap, exhale, breathe in slowly and press button, hold for 10 sec, exhale.
How long to wait before second dose?
30 -60 seconds
Who would benefit from a spacer?
EVERYONE
but mostly for kids and elderly
IF using a spacer and you hear a whistle what does this tell you?
Inhaling too fast
What do you do if you have an infant with a MDI and spacer? When do you know they have gotten the dose?
6 breathes
Common errors of MDI
No shake
no exhale
too fast
True or false: An issue with DPI is that people do not coordinate well enough with inhaling and pressing the release button
False- breathe actuated
What DPI is low resistance? what does this mean?
breezhaler= don’t need a super hard breathe
What DPIs are medium resistance?
Ellipta, genuair, diskus
What DPI’s are high resistance?
Turbuhaler, Handihaler
Why do DPI’s usually not work for young people <5?
Need a certain minimum inspiratory flow
Pros of Turbuhaler
empty indicator, no taste
Steps of using turbuhaler
Twist colour grip as far as it will go then twist back until click, exhale, forcefully breathe, hold for 10 and exhale
Pros of Diskus
delivery is constant across air flow rates
counter
breathe activated
How to use a diskus
Hold in palm with thumbs on grip and push till it clicks, slide lever as far as it will go, exhale, breathe, hold, exhale
Uniqueness of Handihaler’s?
multi breathe for one capsule, capsule!!!!,
How to use Handihaler
remove capsule and flip lid, flip open mouthpiece, load capsule, flip mouth piece closed (will be click), press button, exhale, breathe in (will vibrate), exhale then repeat.
Is it okay that the Handihaler vibrates during inspiration?
Yes-indicates it is being used correctly
True or false: Breezhaler does not use capsules
False
What is a big no no when using a elliptic?
Covering the vents, and closing the cap before taking the dose as it is lost, also tipping it can make it come out the mouth piece
Big difference of using a Genuair?
press down button and will lock to signal empty
What dose red mean on the doses for Ellipta?
<10 doses remaining
What is the general expired for elliptic devices?
6 weeks
For genuair what does red mean on the window?
Not ready for inhalation
What does a red stripe band mean for genuair?
Need new inhaler
What are the pros and cons of SMI?
Pros= slow mist=more time, no effort, counter
Cons= spring dose (hard), no for under 5, no spacer, prime 3 days if Combivent or 7 for Spiriva
How to use a Respimat?
prime, turn base 1/2 Counter clockwise, open, exhale breathe in (don’t cover vents), and click button
What does emphysema means?
Abnormal enlargement of airspace= destruction of walls without obvious fibrosis so low SA= hyperventalation
What is considered chronic bronchitis?
Cough for >3 months for 2 consecutive years
What is the biggest risk factor for COPD?
Smoke
What genetic thingy is related to increased COPD risk?
1-antitrypsin deficiency as this prevents neutrophil elastase destroying elastin= elastic recoil
What of these increases with COPD (RV,IRV,ERV,TV)
RV
True or false; Excessive Mucous secretion does not effect airflow
True
What are some comorbid illnesses with COPD
Lung HTN
muscle wasting
osteoporosis
depression
What are the 3 cardinal symptoms of COPD
SOB
Cough
Phlegm-morning
What are sx of end stage COPD
positions to relieve dypnsea
neck muscles to breathe
pursed lips
larger liver
How do you calculate pack years
(#/d divided by 20) x #years
HOW do we diagnose COPD?
Spirometry of <0.7 ratio
FEV1 is used to stage the disease
Who should we screen for COPD?
smokers/ex smokers >40
persistent cough and sputum
frequency URTI
evening wheeze
What is the MRC dypsnea Scale?
0- breathless after strenuous exercise
1- SOB when hurrying= mild
2- Walks slower and stops for breathe at own pace= moderate
3- Stops for breathe after 100 m=moderate
4- Too breathless to leave house=severe
What number indicates moderate-severe on CAT
> 10
What number on CAT test indicates mild
<10
What is the spirometry readings to diagnose COPD?
Post bronchodilator FEV1<80% andRatio <0.7
What is CTS COPD classification scale?
Mild= FEV1>80%
Moderate= FEV1 50-79
Severe= 30-49%
Very Severe= <30%
What is Gold Stages of COPD
Mild= FEV1>80%
Moderate= FEV1 50-79
Severe= 30-49%
Very Severe= <30%
What is Gold C?
_>2 exacerbations in 1 year or _>1 hospital admit
and mild COPD/CAT<10
What is Gold D?
_>2 exacerbations in 1 year or _>1 hospital admit
and Moderate-Severe COPD/CAT>10
What is Gold A?
<2 exacerbations and no hospital admit
and mild COPD/ CAT<10
What is Gold B
<2 exacerbations and no hospital admit
and Moderate-severe COPD/ CAT>10
Best treatment of COPD? (best risk reduction)
stop smoking
Is it okay to give opioids in end of life care of patient with COPD?
yes- can actually help with breathing
COPD patients need to be active. What is a general exercise RX?
3-5 sessions for 30 minutes, moderate intensity
What is a preventative strategy (not daily drugs) for COPD?
Vaccines
When do we want to supplement treatment of COPD with O2?
When <60mmHg PaO2
The same SABAs are used in COPD BUT what are our SAMA’s?
ipratropium
Which is more effective and quicker SABA or SAMA?
SABA
When would SAMA’s be recommended over SABA’s?
If on beta blocker
What are side effects of SAMA
dry mouth, constipate, no pee, glaucoma
Which LAMA is dosed BID?
aclindinium
Which is thought to be better and why/ LABA vs LAMA
LAMA (tiotropium), may be better tolerated and better at decreasing exacerbations
Why DONT we want ICS in COPD
URTI risk as they are already at risk.
Which LABAs and LAMAs work in minutes
LABA- formoterol, indacterol, olodaterol, vilanterol
LAMA- glycopyrronium
What is dosing for prophylactic azithromycin for COPD?
250mg OD for 1 year
What is MOA of N-acetylcysteine?
mucolytic agent= better for cough phenotype
What is Roflumilast MOA?
PDE4 inhibitor
Side effects of Roflumilast
diarrhea, weight loss, depression
RX for Mild COPD
LAMA OR LABA
Rx for Low acute risk/ moderate COPD
LAMA/LABA
OR
LAMA/LABA/ICS
Rx for high risk and severe COPD?
LAMA/LABA/ICS
or those and macrolide, PDE4,Mucolytic
When do we do lung reduction surgery?
survival Is <2 years and FEV1<25%
Do we ever step down in COPD
generally no, BUT if ICS has side effect you can taper and try other agent
Dose of systemic steroids during acute exacerbation of COPD
30-50 pred
When should antibiotics be given for COPD in acute exacerbation?
2/3 of the following, sputum purulent, increase sputum volume, increased dyspnea
How many AECOPD events are infections and relatively how many are viral?
50% and this is mostly viral
What is antibiotic of choice for AECOPD if needed and low risk
amox, 5-7 days doxy if needed due to allergy
What is antibiotic of choice for AECOPD if needed and high risk
amoxiclav, for 5-10 days or cefuroxime
When are COPD patients good to be discharged?
no SABA more frequently than every 4 hours
can walk, and sleep, and eat
stable for 1 day
True or false: Sacred tobacco is just as bad for you as cigarettes.
FALSE
What is age of the average smoker and the amount of cigarettes a day?
24 years
14 cigs/day
What does it indicate to use if a smoker lights up within 30 minutes of waking?
Very addicted and chances of quitting is reduced by 40%.
What is the rule of 3’s
3 minutes is duration of a Nic fit
3 days for a Nic addiction
3 weeks for psych addiction
How much weight loss Is expected when quitting
5 kg in first 3 months
What types of drugs can cigarets induce metabolism on?
methadone
psychotropic
some oncology agents
What is main cessation method?
cold turkey
True or false Gimmick (potentially scam) products help with cessation)
usually just fidget item and could help if patient says so. if they act as crutch= good
Is e cigs a good alternative/
no still getting too fast of a Nic hit
What is lobelia plant?
its a nicotine like substance that can take the edge off
sort of like prechampix
What is the number one NRT product
Gum
How does silver acetate work
if used with smoke there will be a bitter taste
smokerette lozenges
When do we give 4 mg gum compared to 2 mg
4 mg- >25 cigs or within 30 min of waking
2 mg- <25 cigs and later in morning
How do all NRT options absorb?
buccal
How do you control the release of gum and lozenges?
depends on how much you chew or suck
How do you use gum or lozenge?
chew/suck then park and repeat for 30 minutes
How does acidic/coffee effect NRT?
lowers absorption but just take more/suck or chew more
How long to give NRT after MI?
2 weeks
Which is better prn or schedule NRT?
schedule
How do you dose gum vs how many cigs a person takes
of gum= # of cigs
What’s the general taper with gums?
decrease by half every month
What percentage can get hooked on gum
5%
Can you smoke on NRT?
yes
S/e of gum
irritation, nausea, jaw fatigue
How much nicotine in a patch?
114 mg= DISPOSE CAREFULLY
How much drug distribute in 24 hours with patch?
21mg
Can you shower with patch on?
Yes but do not put new one on after because hydration increases absorb
S/e of patch
local irritation, nausea, sleep dreams (take patch off)
If bad dreams but smoker lights early in the morning what’s the solution?
push through? or other NRT
What are the steps with patches?
1=21 mg for week 1-6
2=14 for 7-8
3= 7mg for 9-10
length doesn’t matter**
What is <100 lbs, CVD risk, or less than 10 sigs with patch?
start at step 2
Can you combo patch with other NRT
yes
What is min/max for cartridges for inhaler for cessation?
6-12 then reduce by 1-2 cartridges a day at week 14
When to use 1 mg lozenge vs 2 mg?
1- <1 pack
2- > 1 pack
What is the general scheduling of lozenges/
1 lozenge every 1-2 hours then decrease time in between
What are we more concerned about? Under or over dosing?
under, they won’t quit or have bad experience if under dose
What’s special about mini-lozenges?
3 x faster and last 10 minutes
What is the fastest NRT product we have?
quick mist
What shouldn’t we do for 15-30 minutes after NRT product?
eat/drink
Dosing schedule of quick mist?
1-2 sprays every 1/2 hour
What is use of Bupropion?
antidepressant so for those that depression is a factor, reduce craving because it increases NA, DA
S/e of bupropion?
seizure, lower weight, insomnia, dry mouth
What is dosing schedule of bupropion?
150 mg OD for 4 days then BID, stop smoking at 1 week (add NRT)
True or false nortriptylline works for cessation?
true
True or false SSRIs works for cessation?
NO
MOA of varenicline?
nicotine agonist
NRT with varenicline?
doesn’t make sense but data is conflicting
Dosing with Champix/
day 1-3= 0.5 OD
4-7= 0.5 BID
8= 1 BID
S/e of Champix
depression, nausea, insomnia, headache
What is cytisine?
basically champ lite
OTC
Questions to ask when a smoker wants to quit?
WHAT HAVE THEY TRIED,
what worked
health status (CVD,Depressed), how many, what time of day
preference
Smoker doesn’t want to gain weight, what product we giving?
bupropion
Can you combo bupropion and NRT
yes
Can you combo bupropion and champix?
yes but s/e worrisome
What for pregnant people?
if they are going to continue to smoke NRT for sure even though no nicotine is best
NO patch, IR only
WE have good products but what must the smoker have to be successful?
MOTIVATION
What are the stages of change?
precontemplation
contemplation
preparation
action
maintenance
Is bupropion as effective as champ or combo NRT?
NO
Is Bupropion 300mg better than 150?
No just as efffective
How do you effectively utilize quit days?
anything to make smoking less enjoyable 2 weeks before quit day
How frequent is smokers cough and what characteristics does it have?
40%
minimal sputum in morning
What happens to cough after quitting?
worsens for 3 months
