Clinical Questions Flashcards
What are the mainstay characteristic of pulmonary hypertension?
Continuous high blood pressure in the PULMONARY arterities
normal pulmonary artery pressure (PAP) = 8 - 20 mmHg
PH = or > 25 mmHg with normal fluid status
What are the different PH groups?
Group 1 = PAH - due to factors like heredity, drugs, HIV, liver disease
(or no cause called primary or idiopathic)
Group 2 = PH due to left heart disease
Group 3 = PH due to lung diseases
Group 4 = chronic thromboembolic pulmonary hypertension (mainly in pulmonary embolism survivors)
Group 5 = PH with unclear mechanism
What drugs cause PAH?
Cocaine
SSRI during pregnancy (of newborn)
Weight-loss drugs (diethylpropion, phendimetrazine, phentermine)
Methamphetamines/
Amphetamines
What is the pathophys of PAH?
Imbalance in substances like: vasoconstrictors (Thrombozane A2 and Endothelin-1) are increased and vasodilator (Prostaglandins) are decreased.
When not treated, the high blood pressure in the pulmonary vasculature can lead to pulmonary artery cell wall thickening and scarring which causes the RIGHT ventricle to work harder at pumping out blood === HEART FAILURE
Patient presents with fatigue, dyspnea, and discoloration of the fingers. Patients vitals include:
Temp 36 C
BP 135/79
HR 122
RR 24
SpO2 97%
Doctors also said her PAP was 45 mmHg. What is most likely the diagnosis? What is a normal PAP range?
Pulmonary Artery Hypertension (PAH)
PAP = 8 - 20 mmHg
Patient presents with fatigue, dyspnea, and discoloration of the fingers. Patients vitals include:
Temp 36 C
BP 135/79
HR 122
RR 24
SpO2 97%
PMH:
Doctors also said her PAP was 45 mmHg. A right catherization was performed, and the vasoreactivity test showed a decrease to 35 mmHg. What is a good treatment recommendation for the PAH?
Oral CCB - nifedipine, amlodipine, diltiazem
NOT verapamil (too much negative inotropic effect)
Patient presents with fatigue, dyspnea, and discoloration of the fingers. Patients vitals include:
Temp 36 C
BP 135/79
HR 122
RR 24
SpO2 97%
PMH:
Doctors also said her PAP was 45 mmHg. A right catherization was performed, and the vasoreactivity test showed a decrease to 42 mmHg. What is a good treatment recommendation for the PAH?
Prostacyclin analogues or agonists
Endothelin receptor antagonists (ERA)
Phosphodiesterase-5 inhibitors (PDE-5i)
or
Soluble guanyl cyclase stimulator (sGC)
What are some supportive medications that may be necessary for PAH patients?
loop diuretics (fluid overload)
Digoxin (increasing CO or HR control)
Antithrombolytic (high pulmonary BP is high risk for blood clots)
What is the warfarin goal for PAH patients?
1.5-2.5
What drugs can cause pulmonary fibrosis?
Amiodarone/ Dronedarone
Bleomycin
Busulfan
Carmustine/ Lomustine
Nitrofurantoin
Sulfalazine
What are the mainstay characteristic of asthma?
Chronic airway inflammation and bronchconstristion
this causes airway obsruction
A 12 yo patient presents with wheezing and chest tightness which began while playing frisbee at a park. This patient has asthma and is currently on a ProAir rescue inhaler. She usually has wheezing at least 4 times a month but rarely twice in one week does she need her rescue inhaler. How would you treat her asthma symptoms?
Step 2:
Already has rescue inhaler…
Add on a low-dose ICS for maintenance like:
-Betaclomethasone (QVAR) 200 mcg daily
-Budesonide (Pulmicort) 400 mcg daily
- Fluticasone (Flovent or Arnuity) 250 mcg daily
- Mometasone
A 9 yo patient presents with wheezing and chest tightness which began while asleep. This patient has asthma and is currently on a ProAir rescue inhaler and Pulmicort 90 mcg 2 inh BID. She usually has wheezing 5 days of the week and wakes up with chest pain 2-3x per week needing her rescue inhaler. How would you classify and treat her asthma symptoms?
Uncontrolled asthma!!!
- switch Pulmicort to to Symbicort (with formoterol) for her maintentance inhaler
-switch Pulmicort to Advair or Breo or Dulera
**may also which rescue inhaler to low ICS + formoterol
What questions should you asking to assess asthma control?
- Daytime asthma symtoms > 2x/week
- Any nighttime awakenings
- SABA used > 2x/week
- Is activity limited due to asthma?
3-4 questions yes = UNCONTROLLED
A 11 yo patient presents with wheezing and chest tightness which began while asleep. This patient has asthma and is currently on a ProAir rescue inhaler and Symbicort 90 mcg 2 inh BID. She usually has wheezing daily and wakes up with chest pain 2-3x per week needing her rescue inhaler. How would you classify and treat her asthma symptoms?
UNCONTROLLED - step 4
- increase Symbicort (Budesonide + Formoterol) to 180 mcg 2 inh BID to make it a MEDIUM dose ICS-LABA
What is the medium daily dose for QVAR?
Beclomethasone
>200 - 400 mcg /day
BID dosing
What is the medium daily dose for Flovent?
Fluticasone
>250 - 500 mcg/day
BID dosing
What is the medium daily dose for Arnuity Ellipta?
> 250 - 500 mcg/day
daily dosing
What is the medium daily dose for Pulmicort Flexhaler?
Budesonide
>400 - 800 mcg/day
BID dosing
What dose (low, medium, or high) is this ICS regimen?
QVAR 40 mcg 2 inh BID
Beclomethasone
Low daily dose
< 200 mcg/day
What dose (low, medium, or high) is this ICS regimen?
Arnuity Ellipta 200 mcg 2 inh once daily
Fluticasone
Medium daily dose = 400 mcg
< 500 mcg BUT > 250 mcg
What dose (low, medium, or high) is this ICS regimen?
Flovent HFA 220 mcg 2 inh BID
Fluticasone
High daily dose = 880 mcg
> 500 mcg
What dose (low, medium, or high) is this ICS regimen?
Pulmicort Flexhaler 90 mcg 2 inh BID
Budesonide
Low daily dose
< 400 mcg
Which long-acting anticholinergic is approved for ASTHMA when ICS/LABA is not enough?
Tiotropium (Spiriva Respimat)
A 5 year old patient has exercise induced asthma and is currently using Ventolin HFA for rescue. What is another option that is NOT an inhaler?
montelukast (Singulair) 4 mg daily in the evening
A 9 year old patient has exercise induced asthma and is currently using Ventolin HFA for rescue. What is another option that is NOT an inhaler?
Montelukast (Singulair) 5 mg daily
What are some general counseling points for Advair Diskus?
Contains ICS
- swish mouth with water after each use
- use QUICK forceful inhalations
- DO NOT SHAKE — DPI
- hold horizontally
What are some general counseling points for Arnuity Ellipta?
Contains ICS
- swish mouth with water after each use
- use QUICK forceful inhalations
- DO NOT SHAKE — DPI
- hold horizontally
What are some general counseling points for Spiriva Respimat?
- use slow, deep inhalations
- a spacer may be used if needed
- Prime the inhaler before use
- you do not need to shake product
What are some general counseling points for QVAR RediHaler
- use slow, deep inhalations
- a spacer may be used if needed
- prime inhaler before use
- you do NOT need to shake product
What are examples DPI inhalers?
Diskus
HandiHaler
Ellipta
Pressair
Flexhaler
RespiClick
What are examples of MPI inhalers?
HFA
Respimat
RediHaler
What medication is appropriate for patients > or = to 6 years old that have allergic asthma that may not be able to tolerate inhalers?
Xolair (Omalizumab)
A patient is on Serevent, QVAR, and Spiriva. What order should she take her inhalers everyday?
- Serevent (Salmeterol)
- Spiriva (Tiotropium)
- QVAR (Beclomethasone)
**wait at least 60 seconds between each inhaler
THEN RINSE MOUTH
Which inhalers can a spacer be used with?
HFA or MDI inhalers
Patients can measure Peak Expiratory Flow Rate daily to help manage their symptoms at home. At what percentage should the patient have a non-emergent intervention?
50-80% of personal best PEFR
Patients can measure Peak Expiratory Flow Rate daily to help manage their symptoms at home. At what percentage should the patient have emergent intervention?
< 50% of patients personal best PEFR
What are the mainstay symptoms of COPD?
Chronic cough, Dyspnea, Sputum, and Wheezing
What is emphysema
destruction of alveoli, the small passages that exchange gases
Gold 1 class
FEV1 > or = 80%
Gold 2 class
Moderate
50 to < 80% FEV1
Gold 3 class
Severe
30 to < 50% FEV1
Gold 4 class
VERY Severe
< 30% FEV1
What do you need to confirm a diagnosis of COPD?
Spirometry finding post bronchodilator FEV1/FVC < 0.7
What assessments can be utilized to see severity of COPD symoptoms?
mMRC 0 -4
CAT 0-40
What are the COPD group (ABCD) assessments?
A - no exacerbations, no severe symptoms
B - no exacerbations, severe symptoms
C exacerbations, no severe symptoms
D - both no exacerbations and severe symptoms
A patient with FEV1/FVC < 0.7 and FEV 40% has a CAT score of 16 and had 1 hospitalized exacerbation in the past year. What is the confirmed diagnosis and classification?
COPD Gold Class 3, Group D
A patient with FEV1/FVC < 0.7 and FEV 40% has a CAT score of 16 and had 2 hospitalized exacerbation in the past year. The patient is currently on Breo Ellipta. Her Esinophil count is 150. What is the recommended treatment?
COPD Gold Class 3, Group D
Add a LAMA
Esinophil count is NOT > 300 BUT is already on both a LAMA + LABA
A patient with FEV1/FVC < 0.7 and FEV 35% has a CAT score of 17 and had 4 hospitalized exacerbation in the past year. The patient is currently on Serevent Diskus 50 mcg 1 inh BID. Her Esinophil count is 416. What is the recommended treatment?
COPD Gold Class 3, Group D
Add a ICS
Eosinophil count is > 300
A patient with FEV1/FVC < 0.7 and FEV 70% has a CAT score of 16 and had no exacerbations in the past year. What is the confirmed diagnosis and classification?
COPD Gold Class 2, Group B
A newly diagnosis patient with FEV1/FVC < 0.7 and FEV 70% has a CAT score of 16 and had no exacerbations in the past year. The patient is currently on no medications. What would the best treatment option be for her?
COPD Gold Class 2, Group B
LAMA or LABA
A patient with FEV1/FVC < 0.7 and FEV 55% has a CAT score of 8 and had 2 exacerbations in the past year. What is the confirmed diagnosis and classification?
COPD Gold Class 2, Group C
A patient with FEV1/FVC < 0.7 and FEV 55% has a CAT score of 8 and had 2 exacerbations in the past year. This patient is currently on Spiriva Handihaler 18 mcg cap daily. What should her treatment regimen be?
COPD Gold Class 2, Group C
Add on a LABA to therapy
What is the only management strategy proven to slow the progression of COPD?
Smoking Cessation
Which treatment is shown to DECREASE exacerbations?
LAMA
(use for Group C or D)
When should you add on a ICS agent to a COPD patient?
Patients with history of exacerbations and high eosinophil count (> 300) which is a marker of inflammation
OR
needs to add a third drug and eosinophil count is > 100
When should antibiotics be started?
If there is increase sputum purulence plus sputum volume or dyspnea
A newly diagnosed COPD patient with FEV1 75%, CAT of 11 and no history of exacerbations has a PMH of BPH and diabetes. He is currently on Proscar and Glucophage. What is the best treatment option for hs COPD?
COPD Gold Class 2, Group B
LABA because of history of BPH
