ch 62 Flashcards
1
Q
sense of breathlessness and tightness in chest, wheezing, dyspnea, and cough are symptoms of
A
asthma
2
Q
chronic cough, excessive sputum, wheezing, dyspnea, poor exercise tolerance are symptoms of
A
COPD
3
Q
What is the most common cause of COPD
A
cigarette smoking
4
Q
Does drug therapy slow the progression of COPD
A
No drug therapy does not slow disease progression, reduce hospitalizations or prolong life.
5
Q
Chronic, progressive, largely irreversible disorder characterized by airflow restrictions and inflammation
A
COPD
6
Q
chronic inflammatory disorder of the airways
A
Ashtma
7
Q
How does asthma work (pharm)
A
The inflammatory process begins with binding of allergen molecules (ie) house dust mite feces) to IgE antibodies on mast cells. This causes mast cells to release an assortment of mediators such as histamine, leukotrienes, prostaglandins and interleukins ->
cause bronchoconstriction and promote infiltration and activation of inflammatory cells. -> These also release mediators -> cause airway inflammation with edema, mucus plugging and smooth muscle hypertrophy -> obstruct airflow
this produces a state of bronchial hyperreactivity where mild triggers such as cold air, exercise, tobacco smoke -> cause intense bronchoconstriction
8
Q
symptoms of COPD result largely from a combo of what 2 processes
A
Chronic bronchitis
Emphysema
both are an exaggerated inflammatory reaction to cigarrette smoke
9
Q
what piece of COPD is defined by chronic cough and excessive sputum
A
Chronic bronchitis
10
Q
what results from hypertrophy of mucus secreting glands in the epithelium of the larger airways
A
chronic bronchitis
11
Q
what piece of COPD is defined as enlargement of the air space within the bronchioles and alveoli brought on deterioration of the walls of these air spaces
A
emphysema
12
Q
what is the big difference and similarity of COPD and asthma
A
Both are inflammatory
COPD is restrictive
13
Q
diagnosis of COPD requires
A
spirometry testing to measure the degree of airway obstruction
14
Q
what spirometry is needed to confirm COPD diagnosis
A
a postchonchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) of less than 0.7 is needed to confirm
15
Q
Preventative drugs for relief of asthma
A
inhaled glucocorticoids
leukotriene receptor antagonists
cromolyn
16
Q
what genetic alteration can also cause COPD
A
A-1 antitrypsin deficiency
Antitrypsin is a protease inhibitor that protects the lungs from enzymatic destruction by proteases
17
Q
Out of COPD and asthma, which one is immune mediated?
A
both
18
Q
2 main pharm classes for asthma and COPD
A
Bronchodilators
Anti-inflammatory agents
19
Q
The principal antiinflammatory drugs are the
A
Glucocorticoids
20
Q
The principal bronchodilators are the
A
B2 agonists
21
Q
What are the 3 advantages for administering drugs by inhalation
A
1) Therapeutic effects are enhanced by delivering drugs directly to their site of action
2) Systemic effects are minimized
3) relief of acute attacks is rapid
22
Q
When 2 inhalations from a MDI is needed, how long should you wait in between each
A
1 min
23
Q
How much of a MDI vs DPI actually reaches the lungs
A
10% for MDI (80% affects oropharynx and 10% is exhaled)
20% for Dry powder inhaler
24
Q
what device is attached directly to the MDI to increase delivery of drug to the lungs and decrease deposition of drug on the oropharyngeal mucosa
A
Spacers
25
what type of delivery system converts a drug solution into a mist that is finer than the inhalers
why is this beneficial
Nebulizers - less drug deposit on the oropharynx and increased drug delivery to lungs
26
what component of COPD gives a wet cough and which for dry cough
Wet - Chronic bronchitis
| dry - Emphysema
27
How much medicine from MDI reaches the lungs when using an inhaler
21% - lungs
28
when you have a sudden death in an asthmatic - is this in your worse asthmatics or your mild?
usually mild cases because they aren't on anything to decrease the inflammation
29
what populations are the MDIs not as good for and why
younger and older due to the lack of hand-breath coordination
30
preferred long term treatment for children of all ages for asthma
inhaled glucocorticoids
31
What is recommended for administration of inhaled glucocorticoids in children younger than 4 years
face mask
32
What leukotriene modifier is approved for children 1-5 years old
Montelukast is the only one approved. (evidence supporting these drugs is lower than the inhaled glucocorticoids)
33
what type of treatment for a pregnant asthmatic
Inhaled glucocorticoids
34
uncontrolled asthma in pregnancy is associated with
greater fetal risks
35
What Leukotriene receptor antagonists are approve have the better safety profile for someone who is pregnant
Montelukast
| Zafirlukast
36
What glucocorticoids are approved for breastfeeding
only inhaled
| systemic is contraindicated
37
Glucocorticoids and older adults
inhaled is safer than systemic
38
What are the most effective drugs available for long term control of airway inflammation?
Glucocorticoids (Budesonide, fluticasone)
39
what is the last ditch effort for CoPD
anti-inflammatories - inflammation is not really the problem
40
how do glucocorticoids work
1) Decreased synthesis and release of inflammatory mediators
2) Decreased infiltration and activity of inflammatory cells
3) Decreased edema of airway mucosa
41
glucocorticoids and B2
may increase the number of bronchial B2 receptors as well as increasing responsiveness to B2 agonists
42
how are glucocorticoids used in asthma and copd
to control inflammation
especially effective for asthma prophylaxis
management of COPD exacerbations
43
first line therapy for management of the inflammatory component of asthma
inhaled glucocorticoids
44
what route of glucocorticoids are very effective and much safer
inhaled as opposed to systemic (oral or IV)
45
Most patients with persistent asthma should use ____ daily
inhaled glucocorticoid
46
when are oral glucocorticoids used
for patients with moderate to severe persistent asthma or for management of acute exacerbations of asthma or COPD
only prescribed when symptoms cannot be controlled with safer meds (inhaled glucocorticoids or inhaled B2 agonists)
treatment should be as brief as possible
47
adverse effects of inhaled glucocorticoids
oropharyngeal candidiasis
dysphonia (hoarseness, difficulty speaking)
adrenal suppression
slow growth in children and adolescents (but do not decrease final adult height)
less is known regarding suppression of growth and development on brain, lungs and other organs because having asthma alone can affect organ growth.
long term use can promote bone loss
prolonged therapy with high dosing might increase risk for cataracts and glaucoma
48
how can you minimize oropharyngeal candidiasis and dysphonia with inhaled glucocorticoids
rinse mouth with water and gargle after each administration
Use a spacer
49
How do you treat oropharyngeal candidiasis when using an inhaled glucocorticoid
antifungal drugs
50
who are at increased risk for adrenal suppression when on glucocorticoids
children, especially those with a low body mass index (BMI)
young children who have used inhaled glucocorticoids for longer than 6 months
51
what signs should you monitor for looking for adrenal insufficiency
hypoglycemia
hypotension
mental status alteration
52
ways to minimize bone loss with long term use of inhaled glucocorticoids
1) use the lowest dose that controls symptoms
2) ensure adequate intake of calcium and vitamin D
3) participate in weight bearing exercises
53
glucocorticoids are intended for ____ therapy
preventive therapy not for aborting an ongoing attack
54
administration instructions when pt is on a inhaled glucocorticoid and a SABA
Take the SABA 5 min before the inhaled glucocorticoid to enhance delivery of the glucocorticoid to the airways
55
What should pt monitor with asthma
```
Monitor and record
Peak expiratory flow (PEF)
symptom frequency and intensity
nighttime awakenings
effect on normal activity
SABA use
```
56
what should pt be advised to wear if they are at risk of adrenal insufficiency associated with long term systemic use
a medical alert bracelet
57
When used acutely (less than ___ days), even at very high doses, oral glucocorticoids do not cause significant adverse effects.
10
58
Potential adverse effects of oral glucocorticoids
```
adrenal suppression
osteoporosis
hyperglycemia
peptic ulcer disease
and in young patients - growth suppression
```
59
why does prolonged glucocorticoid use put the pt at high risk for adrenal suppression
the adrenal cortex decreases their endogenous production of glucocorticoids of its own.
60
If a pt develops adrenal suppression secondary to prolonged glucocorticoid use, what are the precautions
Do not stop glucocorticoid therapy suddenly - fatal - must be gradually tapered to allow the adrenal cortex to ramp up production
During times of sever physical stress when the body would normally increase production - the systemic
glucocorticoids will need to be increased (stress dose) or they could die
61
your continuing a pt on glucocorticoids but you want to switch them from oral to inhaled. What considerations need to be made
adrenal suppression. inhaled is not systemic and if their adrenals are suppressed - must be given supplemental oral and tapered.
62
___________ are required for recovery of adrenocortical function
several months
63
inhaled glucocorticoid formulated for nebulized dosing
Budesonide suspension (Pulmicort respules)
64
What is Budesonide suspension (Pulmicort respules) approved for
maintenance therapy of persistent asthma in children 1-8 years old.
65
```
Budesonide suspension (Pulmicort respules) improvement after start of treatment should begin in
max benefits may take?
```
2-8 days
| max benefits may take 4-6 weeks to develop
66
name the oral glucocorticoids approved for therapy of asthma
Methylprednisolone
Prednisone
Prednisolone
dosage is all the same for these
67
How is dosing done for oral glucocorticoids to keep the pt free of adrenal suppression symptoms
Highest dose on day one then tapered down with gradually decreasing dosing
for long term treatment - alternate day dosing is often used
68
what should be monitored for adrenal supression
hypoglycemia
hypotension
mental status changes
69
When should you check for adrenal suppression
when a child is on inhaled glucocorticoids for longer than 6 months
70
contraindication for inhaled glucocorticoids
pt with persistently positive sputum cultures for Candida Albicans (not contraindicated in oral )
71
What should pt be taught to monitor with asthma
```
Monitor peak expiratory flow
symptom frequency and intensity
nighttime awakenings
effect on normal activity
SABA use
```
72
Beclomethasone dipropionate (QVAR)
Budesonide (Pulmicort Flexhaler, Pulmicort respules)
Ciclesonide (Alvesco)
Flunisolide (Aerospan)
Fluticasone propionate (Flovent HFA, Flovent Diskus)
Mometasone Furoate (Asmanex Twisthaler)
Inhaled glucocorticoids
73
Methylprednisolone
Prednisolone (Flo-pred)
Prednisone
oral glucocorticoids
74
Montelukast, oral (Singulair)
Zafirlukast, oral (Accolate)
Zileuton, oral (Zyflo)
Leukotriene Receptor Antagonists (LTRAs)
75
Albuterol (ProAir HFA, ProAir RespiClick, Proventil HFA, Ventolin HFA)
Levalbuterol (Xopenex, Xopenex HFA)
Bronchodilators
B2 adrenergic agonist
SABA (short acting Beta2 Agonist)
76
```
Arformoterol (Brovana)
Formoterol (Foradil Aerolizer)
Indacaterol (Arapta Neohaler)
Olodaterol (Striverdi Respimat)
Salmeterol (Serevent Diskus)
```
Inhaled Long Acting B2 Agonist
LABA
77
Albuterol, oral (VoSpire ER)
| Terbutaline
Oral LABA
78
Aminophylline, oral
| Theophylline, oral (Theo-24)
Methylxanthines
79
```
Aclidinum bromide, inhaled
Glycopyrronium bromide, inhaled
Ipratropium, inhaled (Atrovent HFA)
Tiotropium, inhaled (Spiriva)
Umeclidinium, inhaled
```
Anticholinergics
80
This med group suppresses the effects of leukotrienes which in ______, these drugs can decrease bronchoconstriction and inflammatory responses
Leukotriene receptor antagonists (LTRAs)
| Asthma
81
Which LTRAs block leukotriene synthesis
Zileuton
inhibits 5-lipoxygenase (enzyme that converts arachidonic acid into leukotrienes)
82
Which LTRAs block leukotriene receptors
Zafirlukast
| Montelukast
83
When are LTRAs used
Second line therapy when an inhaled glucocorticoid cannot be used and as add on therapy when an inhaled glucocorticoid alone is inadequate in asthma
84
Adverse effects of LTRAs
neuropsychiatric effects, including depression, suicidal thinking and suicidal behavior
85
LTRA ______approved for asthma prophylaxis and maintenance therapy for what ages
Zileuton
| adults and children 12 and older
86
Can Zileuton be used to abort an ongoing asthma attack
No, effects are seen within 1-2 hrs of dosing
87
Zileuton inhibits what enzyme
5-lipoxygenase
88
Zileuton metabolism
rapidly metabolized by liver
89
Adverse effects of Zileuton
can injure the liver (watch ALT- will be increased with injury)
neuropsychiatric effects
90
What is the recommended schedule for monitoring ALT (alanine aminotransferase) activity when taking Zileuton
once a month for 3 months
once every 2-3 months for the remainder of the 1st yr
periodically afterwards
91
drug to drug interactions for Zileuton
metabolized by Cytochrome P450
using together with Theophylline can markedly increase theophylline levels
can increase levels of
- Warfarin
- Propanolol
92
which LTRA is approved in adults and children 5 years and older
Zafirlukast
93
Which LTRAs are block leukotriene receptors
Zafirlukast (Accolate)
| Montelukast (Singulair)
94
Which LTRAs are metabolized by cytochrome P450
all of them
95
Which LTRA does not increase theophylline or warfarin levels
Montelukast (Singulair)
96
Which LTRAs have the adverse side effect of Churg-Strauss syndrome?
Zafirlukast (Accolate)
| Montelukast (Singulair)
97
What seems to contribute to Churg-Strauss Syndrome
in most cases symptoms developed when glucocorticoids were withdrawn.
98
What is Churg-Strauss Syndrome symptoms
potentially fatal disorder
weight loss
flulike symptoms
pulmonary vasculitis
99
Which LTRA does not seem to cause liver injury
Montelukast (Singulair)
100
What LTRA does food affect absorption?
| what does that look like?
food reduces absorption by 40%
| Administer drug at least 1 hour before meals or 2 hours after
101
What LTRA has the longest half life that is increased in older adults
Zafirlukast
10 hours but may be as long as 20 hours in older adults
102
Adverse effects of Zafirlukast
```
headache
GI disturbances
Arthralgia
myalgia
neuropsychiatric effects
Churg-Strauss syndrome
liver injury
```
103
In Zafirlukast rarely pt have developed clinical signs of liver injury mainly in what population
females
104
Which LTRA can increase levels of propanolol
Zileuton
105
Which LTRA has GI adverse effects listed along with arthralgias and myalgias
Zafirlukast
106
Which LTRA is the most commonly used
Montelukast (Singulair)
107
indications for Montelukast (Singulair)
1) Prophylaxis and maintenance therapy for asthma in pt at least 1 year old
2) prevention of exercise induced bronchoconstriction in pt at least 15 years old
3) relief of allergic rhinitis
108
which LTRA has the fastest symptom improvement
Zileuton (1-2 hours) - not a rescue
109
which LTRA is highly bound (more than 99%) to plasma proteins
Montelukast (Singulair)
110
Rule of 2s
Asthma are you in control?
111
anticonvulsant that induces P450
Phenytoin
112
When glucocorticoids create problems, what is an alternative drug for management of inflammation in asthma
Cromolyn administered by nebulizer
113
Disadvantages of Cromolyn
max effects take several weeks to develop
| Dosing is 4 xs / day
114
Advantage of Cromolyn
safest of all antiasthma medications. Significant effects occur in fewer than 1 in 10,000 patients (occasionally a cough or bronchospasm occurs)
115
Bronchodilators are used in patients with
asthma and copd
116
Short acting B2 agonists are approved for children ages
2 and older (used in younger)
117
Anticholinergics in children
ages 11 and older
118
Methylxanthines and children
all children and even neonates
119
bronchodilator approved in neonates
Methylxanthines
120
Bronchodilators and pregnancy
B2 agonists may cause uterine relaxation, benefits greater than risks
inhaled anticholinergics are among the safer drugs for pregnant women
Methylxanthines are a no
121
Breastfeeding and bronchodilators
B2 agonists okay
inhaled anticholinergics okay
methylxanthines are no
122
Older adults and bronchodilators
B2 agonists and inhaled anticholinergics are a risk vs benefit
systemic anticholinergics are a no go
methylxanthines are no
123
How do B2 agonists work in lungs
smooth muscle - promote bronchodilation which relieves bronchospasm
Suppress histamine release in lung
increase ciliary motility
124
All oral B2 agonists are _____ acting
long
125
when are SABAs taken
PRN to abort an asthma attack
in patients with EIB (exercise induced bronchospasm) they are taken before exercise to prevent an attack from occurring
hospitalized patients undergoing a severe acute attack - nebulized SABA is treatment of choice
126
_______ are preferred over _____ for patients with stable COPD
LABAs are preferred over SABAs in patients with stable COPD.
127
LABAS in asthma
not first line therapy
if used they must ALWAYS be combined with a glucocorticoid. LABA monotherapy associated with death in asthma patients. FDA recommends both drugs in the same inhaler.
128
oral B2 agonists are ____ line drugs
second line -
129
Adverse effects of inhaled SABAS
tachycardia
angina
tremor
130
oral B2 agonist adverse effects
selectivity is relative, not absolute
excessive dosing can cause angina and tachydysrhythmias
Pt report chest pain and changes in HR or rhythm
131
what type of schedule should LABAS and oral B2 agonists have
fixed schedule not PRN and always in combo with inhaled glucocorticoid
oral B2 agonists also fixed
sustained release preps swallowed intact without crushing or chewing
132
Nebulizer delivers dose slowly over several minutes which does what in the lungs
as the bronchi gradually dilate, the drug gains deeper and deeper access to the lungs
133
What 3 single agent inhaled LABAS are approved for treatment of asthma
salmeterol
formoterol
arformoterol
134
B2 agonist MDI, DPI dosing schedule
initial dosing is 1-2 inhalations spaced 1 min apart 3-4 times per day
135
what LABA is approved for asthma but only comes in a combo with glucocoritcoid
Vilanterol (fluticasone/vilanterol -Breo Ellipta)
| umeclidinium/vilanterol - Anoro Ellipta
136
How often do you use a LABA
every 12 hours
137
What oral B2 agonists are approved for long term control of asthma
Albuterol and Terbutaline
| Dosing is 3-4 times per day
138
contraindications for systemic B2 agonists (oral, parenteral)
Tachydysrhythmias or tachycardia associated with digitalis toxicity
Use with caution in patients with diabetes (hyperglycemia - breaks down glycogen to glucose in liver and skeletal muscles), hyperthyroidism, organic heart disease, HTN, angina
139
theophylline
| caffeine
Methylxanthines
140
what do Methylxanthines do
```
CNS excitation
Bronchodilation
cardiac stimulation
vasodilation
diuresis
```
141
Theophylline is used in ____ for ____
asthma
bronchodilation
sometimes in COPD
narrow therapeutic range
142
Metabolism of Theophylline
smoking tobacco or marijuana accelerates metabolism and decreases half life
Metabolism is slowed in certain pathologies - heart disease, liver disease, prolonged fever
CYP (cimetidine, fluoroquinolone abx decrease metabolism)
(phenobarbital accelerate metaoblism)
143
Symptoms of Theophylline tox
```
nausea
vomiting
diarrhea
insomnia
restlessness
severe dysrhythmias (V-fib)
convulsions that are highly resistant to treatment
death from cardiopulmonary collapse
```
144
Treatment of Theophylline tox
Stop med
get a serum level
Absorption decreased with charcoal with a cathartic in event of acute overdose.
Ventricular dysrhythmias respond to lidocaine or amiodarone.
IV benzos such as diazepam may help control seizures
145
Theophylline and caffeine
similar properties
caffeine can intensify the adverse effects of theophylline on the CNS and heart
can compete for drug metabolizing enzymes causing theophylline levels to rise
Pt on theophylline should avoid caffeine containing beverages and other sources of caffeine
146
Drugs that reduce theophylline levels
Cyp accelerators
phenobarbital
phenytoin
rifampin
also smoking and second hand smoke (tobacco or marijuana - result in decreased drug levels
if a pt stops smoking but drug amount is not decreased, at risk for tox
147
Drugs that increase theophylline levels
```
Cimetidine
fluoroquinolone abx (ciprofloxacin)
```
148
Theophylline pt ed
if miss a dose, do not double next dose
swallow enteric coated and SR formulations without crushing or chewing
Do not drink caffeine
call for nausea, vomiting, abd discomfort, diarrhea, insomnia, restlessness, palpitations- theophylline tox
Do not smoke tobacco or marijuana
149
Anticholinergic drugs are only approved for ______ (resp )
COPD
150
Short acting inhaled anticholinergic that is approved for COPD but often used off label for asthma
Ipratropium (Atrovent)
151
What are the LAMAS approved for COPD
Long acting muscarinic antagonists
Aclidinium
Tiotropium
Umeclidinium
152
Atrovent works by
blocking muscarinic cholinergic receptors in the bronchi to prevent bronchoconstriction
effective against allergen induced asthma and EIB
153
Most common adverse effects of Atrovent
dry mouth
irritation of pharynx
may raise intraocular pressure in pt with glaucoma
154
Tiotropium
LAMA - long acting muscarinic antagonist
| approved for maintenance therapy of bronchospasm associated with COPD
155
How often do you take Tiotropium
once a day
156
Adverse effects of Tiotropium
dry mouth
| systemic anticholinergic effects (constipation, urinary retention, tachycardia, blurred vision) are minimum
157
Aclidinium
Tiotropium
Umeclidinium
Long Acting Muscarinic Antagonist (LAMA)
158
dry mouth pt education for Tiotropium
```
suck on sugarless hard candy for relief
high intake of candy contain sorbitol and xylitol can cause diarrhea.
saliva substitutes (Aquoral, Biotene) are available OTC
```
159
Aclidinium
LAMA indicated for management of bronchospasm associated with COPD.
160
Peak levels of Aclidinium occur within ____ min of drug delivery
10 - however it is intended only for maintenance therapy and not for acute symptom relief
161
adverse effects of Aclidinium
headache
nasopharyngitis
cough
theoretical muscarinic that have not been reported
162
Umeclidinium (Incruse Ellipta)
Newest LAMA
management of bronchospasm associated with COPD
available single agent
also available combo (LABA vilanterol as Anoro Ellipta)
163
what food allergy may cause a hypersensitivity for Umeclidinium (Incruse Ellipta)
Contains lactose
| those with a milk protein allergy
164
Glucocorticoid/LABA combos
used in asthma and COPD
Glucocorticoids - anti-inflammatory
LABAs - Bronchodilation
165
B2 agonist/Anticholinergic Combos
optimized/enhanced bronchodilation
only for COPD
B2 agonists promote by stimulating adrenergic receptors which relaxes smooth muscle in the airways
Cholinergic antagonists do this by blocking cholinergic receptors which relaxes smooth muscle tone by preventing stim of cholinergic receptors
166
Single most useful test of lung function
FEV1
167
How do you do the FEV1
pt inhales completely and then exhales as completely and forcefully as possible into the spirometer
results are compared to a predictive normal value based on age, sex, height, weight
168
Pt with ______ pulmonary disease will have a decreased FEV1
obstructive
169
the total volume of air the patient can exhale after a full inhalation (pulmonary function test)
FEV1
170
what is used to distinguish obstructive from restrictive pulmonary disease
FEV1 divided by FVC
171
For obstructive pulmonary disease the FEV1/FVC will be
decreased < 0.7
172
For restrictive pulmonary disease the FEV1/FVC will be
normal or increased (1+)
173
Obstructive is you cant breathe ___
out
174
Restrictive is you cant breathe __-
in
175
Maximal rate of airflow during expiration
PEF (peak expiratory flow)
176
what is PEF used for
monitor but not diagnose asthma
177
To determine PEF
the patient exhales as forcefully as possible into a peak flowmeter
178
PEF and FEV1
results are approx equal but FEV1 is more accurate because it measures airflow in the large and small airways whereas PEF measures airflow in large airways only
PEF is home device and should be done every morning to identify when pt are developing complications before the symptoms arise
179
What are the four classes of asthma severity
1) intermittent
2) mild persistent
3) moderate persistent
4) severe persistent
180
The classification of asthma severity has 2 domains
impairment
| risk
181
As your asthma symptoms worsen and you climb the classifications of severity your FEV1 ____ and your FEV1/FVC ____
decreases
| drops
182
all asthma pt starting with step 1 need
inhaled SABA PRN
183
All asthma pt except for step 1 need
SABA PRN
| inhaled glucocorticoid
184
When you move an asthma pt up a step
dosage of the control medication is increased or another control med is added or both
185
After a asthma pt has a period of sustained control
moving down a step should be trialed
186
A pt diagnosed with intermittent asthma
PRN use of SABA
187
Pt with moderate persistent asthma
SABA PRN
inhaled glucocorticoid
LABA
188
drugs for severe asthma exacerbation
O2 for hypoxemia
systemic glucocorticoid to reduce airway inflammation
neb high dose SABA to relieve airflow obstruction
neb Atrovent to further reduce airflow obstruction
After discharge oral glucocorticoid taking for 5-10 days
189
Exercise induced Bronchospasm usually starts
peaks?
resolves?
either during or immediately after exercise, peaks 5-10 min and resolves 20-30 min later
190
To prevent EIB
SABA or cromolyn
SABA preferred and give right before exercise
Cromolyn 15 min before
191
asthma triggers and allergens
```
house dust mite
warm-blooded pets
cockroaches
molds
tobacco smoke
wood smoke
household sprays
```
192
rule of 2s
if your not in control
nighttime awakenings 2/month
use SABA 2/week
refilling your SABA more than 2/year
193
classification of COPD by severity
1) mild
2) moderate
3) severe
4) very severe
194
Treatment goals of COPD
reduce symptoms
improve the patients health status
increase exercise tolerance
reduce risks and mortality
195
COPD class
few symptoms, low risk
mild/moderate airflow limitation + low symptom scores + 1 or fewer exacerbations per year
Group A
196
COPD class
increased symptoms, low risk
mild/moderate airflow limitation + low symptom scores +1 or fewer exacerbations per year
Group B
197
```
COPD class
few symptoms , high risk
```
severe/very severe airflow limitation + high symptoms scores + 2 or more exacerbations per year
Group C
198
```
COPD class
increased symptoms , high risk
```
severe/very severe airflow limitation + high symptoms scores + 2 or more exacerbations per year
Group D
199
FEV1/FVC >= 80%
mild COPD
200
FEV1/FVC 50-79%
moderate COPD
201
FEV1/FVC 30% - 49%
Severe COPD
202
FEV1/FVC <30%
Very Severe COPD
203
Group A COPD treatment
SABA
| consider LAMA or LABA
204
Group B COPD treatment
SABA
| LAMA or LABA or a combination of LAMA/LABA for management of persistent symptoms
205
Group C COPD treatment
SABA
LAMA
management of persistent symptoms - combo LAMA/LABA (preferred) or LABA/IGC
206
Group D COPD treatment
```
SABA
LAMA or LAMA/LABA or ICG/LABA
management of persistent - Combo - LAMA/LABA/IGC
if they continue, consider adding
-Roflumilast
-Azithromycin
```
207
Managing of COPD exacerbations
LAMAS have demonstrated better outcomes for exacerbations than LABAS
systemic glucocorticoids
Abx for s/s of infection
oxygen - to maintain sats of 88% - 92%
