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Pharm > Cardiopulmonary: Asthma > Flashcards

Cardiopulmonary: Asthma Flashcards

1
Q

Asthma is

A

a chronic, reactive, obstructive airway disorder characterized by narrowing of the airways due to bronchospasm, airway inflammation, and increased secretions.

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2
Q

Asthmatics cannot achieve ____, resulting in _____

A

cannot achieve normal air flow rates resulting in uneven lung aeration and VQ mismatch

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3
Q

VQ mismatch

A

decreased ventilation, normal perfusion

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4
Q

hallmark of asthma

A

inflammation, leading to bronchospasm

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5
Q

why are we aggressive in asthma treatment?

A

to prevent remodeling as much as possible

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6
Q

in asthma, wheezing is secondary to

A

turbulence and mucosal vibrations

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7
Q

Pathophysiology of asthma [structural]

A

airway obstruction and remodeling.

inflammation secondary to hyper responsiveness of airways

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8
Q

remodeling defined

& What does it lead to

A

structural changes as a result of constantly being “under attack”. this leads to decreased lung recoil and compliance.

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9
Q

management of chronic asthma begins with evaluating

A

FEV-1/FVC

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10
Q

pathophysiology of asthma [cellular]

A

mast cell degranulation, releasing histamine
inflammatory cytokines
eosinophil infiltration
leukotrienes

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11
Q

Forced Expiratory Volume (FEV1)

A

max amount of air one can exhale forcefully and rapidly in the first second after a deep inspiration (time based)

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12
Q

what is FEV1 based on?

A

body size and race

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13
Q

Forced Vital Capacity (FVC)

A

the maximum amount of air one can exhale forcefully and rapidly after a deep inspiration. Is there air remaining/trapped? (amount based)

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14
Q

FEV1:FVC Ratio is used for what?

A

to measure obstruction

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15
Q

Normal FEV1:FVC ratio

5-19 y/o

A

85%

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16
Q

Normal FEV1:FVC ratio

20-39 y/o

A

80%

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17
Q

Normal FEV1:FVC ratio

40-59 y/o

A

75%

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18
Q

Normal FEV1:FVC ratio

60-80 y/o

A

70%

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19
Q

goal FEV1/FVC ratio for someone being treated for asthma

A

80% or better

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20
Q

Categories of Asthma based on EPR-3 Guidelines: Step 1-6

A

1: intermittent
2: mild persistent
3, 4: moderate persistent
5, 6: severe persistent

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21
Q

At which step of asthma should specialist consultation occur?

A

Around step 4

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22
Q

Asthma treatment varies by

A

step of classification

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23
Q

As FEV1 goes down,

A

so does the FEV1/FVC ratio

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24
Q

The emphasis of asthma treatment is on

A

asthma control, reducing impairment and future risk

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25
Q

Initial asthma management is based off of

A

categorization of severity

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26
Q

subsequent asthma management is based off of

A

assessment of control using validated instrument

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27
Q

example of validated instrument used to assess asthma control

A

PFT

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28
Q

EPR: for patients in steps 2-4 with allergic asthma, what should be considered?

A

subQ allergen immunotherapy

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29
Q

budesonide is a

A

steroid

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30
Q

formoterol is a

A

LABA

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31
Q

albuterol is a

A

SABA

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32
Q

LAMA

A

muscurinic

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33
Q

Two major types of therapies for asthma treatment

A

bronchodilators

immunosuppressants

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34
Q

Benefits of inhalation therapies

A

doses are much smaller inhaled than if they were given systemically, so you have a reduction in adverse effects without a reduction in efficacy

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35
Q

what is the goal of long term control versus short term control of asthma?

A

prevention of exacerbation

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36
Q

long term asthma therapy

A

immunosuppresants

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37
Q

short term asthma therapy

A

bronchodilators

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38
Q

3 divisions of bronchodilators

A

beta 2 agonists
methylxanthines
anticholinergics

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39
Q

short acting beta 2 agonist bronchodilators

A

albuterol

levalbuterol

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40
Q

albuterol vs levalbuterol

A

isomer of albuterol, levalbuterol has less side effects than albuterol.

unfortunately, it is expensive and reserved for those who have failed or become refractory to albuterol.

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41
Q

long acting beta 2 agonist bronchodilator

A

formoterol

salmeterol

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42
Q

albuterol can be administered

A

po or inhaled

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43
Q

example of methylxanthine bronchodilator

A

theophylline

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44
Q

theophylline can be administered

A

oral or iv

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45
Q

examples of anticholinergic bronchodilators

A

ipratropium
tiotropium

(both inhaled)

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46
Q

Albuteral and levalbuterol are for ____ while formoterol and salmeterol are for _____

A

rescue ; maintenance

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47
Q

long acting beta 2 agonists are used in conjunction with

A

corticosteroids

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48
Q

you will see salmeterol or formoterol used in conjunction with ____ and why

A

corticosteroids ; because they are long acting beta 2 agonist bronchodilators.

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49
Q

what is the onset of short acting beta 2 agonist bronchodilators?

A

15 minutes

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50
Q

true or false, everyone diagnosed with asthma gets a SABA

A

true

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51
Q

SABAs are also used for

A

prevention of exercise induced asthma

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52
Q

as a rule of thumb, what would insight would you gain if your patient tells you they have used one small canister of their SABA in one month?

A

that they are well controlled

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53
Q

as a rule of thumb, what would insight would you gain if your patient tells you they have used two or more small canisters of their SABA in one month?

A

that they need more anti inflammatory effects

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54
Q

beta-2 agonists and MAOIs or tricyclic anti depressants

A

HTN crisis

55
Q

Beta-2 agonists plus corticosteroids

A

more effective than increased doses of corticosteroids on their own

56
Q

adding beta-2 agonists to an ICS corticosteroid regimen can do what to ICS dose?

A

decrease by 50%

57
Q

T or F, beta-2 agonists have no appreciable anti-inflammatory action

A

true

58
Q

long term use of beta-2 agonists may result in

A

tolerance

59
Q

if pt is getting tolerant to beta2 agonist, what should provider do

A

change agents or increase dose/freq.

60
Q

if someone has an asthma exacerbation, what should provider ask them to demonstrate

A

how they use their inhaler/if their technique is incorrect

61
Q

Per FDA, LABAs should only be used

A

in combo with other agents such as corticosteroids

62
Q

Theophylline is generally not recommended for

A

exacerbations

63
Q

anticholinergic bronchodilators are aka

A

muscarinics

64
Q

Ipratropium is a

A

short acting muscarinic antagonist (SAMA)

65
Q

___ includes anticholinergics, while ___ does not

A

GINA, EPR

66
Q

Ipatropium is not actually indicated for asthma but

A

it is used all of the time, especially in first 24 hours via neb and is part of the GINA guideline.

67
Q

why give beta 2 agonist with an anticholinergic in asthma exacerbation?

A

they both bronchodilate but via different mechanisms, you’ll have a more effective bronchodilator.

68
Q

tiotroprium is a

A

long acting muscarinic antagonist (LAMA)

69
Q

tiotroprium is not

A

in the EPR but is FDA approved for asthma

70
Q

4 immunosuppressant groups used for long term asthma control

A

corticosteroids
mast cell antagonists
leukotriene antagonists
monoclonal antibodies/biologics

71
Q

PO corticosteroids used for asthma (2)

A

prednisone

methylprednisolone

72
Q

inhaled corticosteroids used for asthma (2)

A

beclomethasone

flunisolide

73
Q

inhaled mast cell antagonist

A

cromolyn

74
Q

PO leukotriene antagonists (3)

A

zafirlukast, montelukast, zileuton

75
Q

corticosteroids are first line treatment starting at what asthma step, typically?

A

step 2

76
Q

t or f - corticosteroids are not for acute attacks

A

true, ok for an exacerbation.

77
Q

inhaled steroids are best for

A

long term use - control

78
Q

what route of steroids for acute attack?

A

IV or Oral

79
Q

short term oral corticosteroids use of 3-10 days is indicated for what?

A

to gain control of inadequately controlled persistent asthma.

80
Q

long term inhalation of corticosteroids is

A

used for prevention. the preferred long term control therapy for all ages.

81
Q

adverse effects of inhaled corticosteroids (4)

A

cough
dysphonia
thrush
headache

82
Q

what should patient take with po corticosteroid?

A

h2 blocker

83
Q

adverse effects of PO corticosteroids (4)

A

reversible glucose increase
increased appetite
fluid retention
peptic ulcer

84
Q

adverse effect of high dose PO glucocorticoid

A

adrenal axis suppression

85
Q

how to maximize effect of inhaled corticosteroids?

A

use of spacer

86
Q

how to minimize local side effects of inhaled corticosteroids?

A

rinse mouth after

87
Q

t or f - preparations of each type of inhaled steroid are NOT interchangeable

A

true

88
Q

corticosteroids are NOT

A

for acute attacks

89
Q

what to look for in long term corticosteroid use?

A

growth issues

90
Q

if growth issues occur in long term corticosteroid use, what is a proper alternative?

A

mast cell agents

91
Q

MoA of Cromolyn sodium, a mast cell stabilizer

A

acts as an anti inflammatory, stabilizing mast cell membranes, inhibiting activation and release of mediators from eosinophils and epithelial cells like histamine and leukotrienes.

92
Q

mast cell stabilizers are used mainly in __ , why?

A

children

weaker drug and does not have growth issues like steroids do

93
Q

mast cell stabilizers as compared to beta agonists

A

less side effects but takes longer to get results. should never be used as a rescue.

94
Q

Cromolyn, a mast cell stabilizer, is most useful in

A

younger and allergic asthmatics with mild persistent asthma

95
Q

patient education re: cromolyn sodium, a mast cell stabilizer

A

most patients take a while to see clinical effect.

96
Q

adverse effects of cromolyn, a mast cell stabilizer (2)

A

cough and congestion

rare

97
Q

Mast cell stabilizer (Cromolyn) as compared to corticosteroid

A

considered weak in comparison

98
Q

why are mast cell stabilizers (cromolyn) used more frequently in children?

A

they pose no risk of growth suppression

99
Q

indication for cromolyn, a mast cell stabilizer

A

prevention of exercise induced asthma

100
Q

Montelukast is a

A

leukotriene modifier

101
Q

MoA of montelukast and zafirlukast (leukotriene modifiers)

A

Blocks leukotriene receptors on inflammatory cells and smooth muscle

102
Q

when should leukotriene modifiers be used?

A

in maintenance when a patient is stable. is not a tx for acute asthma.

103
Q

leukotriene modifiers in asthma exacerbation

A

no help

104
Q

MoA of zileuton, a leukotriene modifierwh

A

stops the synthesis of leukotrienes via lipoxygenase inhibition

105
Q

Leukotriene modifiers are given

A

PO as systemic treatment

106
Q

Leukotriene modifiers as compared to corticosteroids

A

well tolerated and have minimal side effects but are less effective

107
Q

drug interactions involving leukotriene modifiers

A

these drugs are enzyme inhibitors

108
Q

-lukast drugs: enzyme inhibition

A

will inhibit warfarin metabolism

109
Q

zileuton: enzyme inhibition leads to

A

will inhibit warfarin and theophylline metabolism

110
Q

What lab should be monitored when someone is on a leukotriene modifier?

A

LFT - baseline and q6 months

111
Q

Which monoclonal antibody is indicated for asthma?

A

omalizumab, an IgE-binder

112
Q

MoA of Omalizumab

A

forms complexes with IgE and prevents binding to receptors, thus limiting inflammatory mediator release.

113
Q

Omalizumab is indicated in

A

patients >12 y/o with moderate to severe asthma who have failed all other traditional agents.

114
Q

Example of a novel asthma therapy

A

dupilumab

115
Q

MoA of dupilumab

A

Inhibits IL-4 and IL-13, reducing symptoms

116
Q

Dupilumab is indicated in

A

patients with eczema
in patients with asthma, it is similar indication as omalizumab - patients in steps 5 or 6 who have failed other therapies.

117
Q

Goal of ED care: asthma

A

oxygen management

118
Q

emergency asthma care is comprised of

A

anti inflammation, frequent bronchodilation, and potential for antibiotic

119
Q

What meds would you anticipate being administered in an acute asthma exacerbation in the ED?

A
  • IV corticosteroid methylprednisolone before switching to PO prednisone
  • albuterol/ipatropium for first 24 hours, then albuterol alone,
  • magnesium
120
Q

rationale for antibiotics in asthma exacerbation

A

want to avoid CAP superimposed on exacerbation

121
Q

Empiric antibiotics and asthma

A

avoid unless you have a reason to r/o pneumonia

122
Q

What asthma meds should be avoided in acute asthma exacerbation? (3)

A
  • leukotriene based agents because they will not have an effect
  • theophylline because of AEs and narrow levels
  • empiric abx
123
Q

Monitoring of chmronic asthma

A

assess control and set up action plan

124
Q

what modifiable factors which make asthma worse can be controlled? (5)

A 
tobacco smoke
dust mites
animal dander
cockroaches
mold
125
Q

What tools can be used to assess progress in chronic asthma?

A

peak flow meter

asthma diary

126
Q

Metered dose inhalers and soft mist inhalers administration characteristics

A

slow and deep inhalation

127
Q

dry powder inhaler characteristic of administration

A

rapid and deep

128
Q

what is the purpose of an inhaler spacer?

A

disperses aerosol into the spacer, decreasing the droplet size and thus decreasing oral deposition of the aerosol.

129
Q

skipping slide 64 until lecture

A

ok

130
Q
A

LABAs are used in conjunction wit

131
Q

tolerance to beta-2 agonists may necessitate what from the provider?

A

change in beta-2 agonist or increased steroid dose

132
Q

tolerance to beta-2 agonists may necessitate what from the provider?

A

change in beta-2 agonist or increased steroid dose

133
Q

tolerance to beta-2 agonists may necessitate what from the provider?

A

change in beta-2 agonist or increased steroid dose

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