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Exam 2- Practical Therapeutics > COPD exacerbation > Flashcards

COPD exacerbation Flashcards

1
Q

Mucolytics function

  • which drugs are mucolytics
  • how are they administered
  • what ADR can they cause?
A

1) drugs that react directly with mucus to make it less VISCOUS - makes coughing more productive
2) two agents:

  • acetylcysteine
  • hypertonic saline

both agents are administered via inhalation and unfortunately can trigger FURTHER BRONCHOSPASM

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2
Q

Acetylcysteine indications

A

mucolytic, acetaminophen OD

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3
Q

Acetylcysteine MOA

A

lowers mucus viscosity allowing for more productive cough

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4
Q

acetylcysteine routes CAUTION

A
  1. nebulized inhalation
    1. oral tabs, IV (Acetaminophen OD)
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5
Q

acetylcysteine adr

A

bronchospasm

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6
Q

hypertonic saline indications

A

mucolytic

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7
Q

MOA of hypertonic saline

A

restores moisture to pulmonary system and allows for more productive cough

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8
Q

Route hypertonic saline

A

Nebulized inhalation preferred

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9
Q

ADR hypertonic saline

A

bronchospasm

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10
Q

Cough suppressants

  • what does coughing involve?
  • how is coughing initiated?
  • what is cough beneficial for?
  • when should a cough be suppressed?
A
  • coughing is a complex reflex involving the CNS, PNS, and muscles of respiration
  • can be initiated by the irritation of the bronchial mucosa or stimuli at sites distant froom the RT
  • cough is often beneficial when removing foreign matter and excessive secretions- these should not be typically suppressed
    • non-productive coughs that create discomfort or deprive a patient of sleep are reasonoable to suppress
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11
Q

Antitussive drugs

A
  1. suppress cough but do NOT treat the underlying condition
  2. opioid antitussives-
    1. codeine
  3. non- opioid antitussives
    1. benzonotate
    2. antihistamines ( prromethazine, diphenhydramine)
    3. dextromethorphan
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12
Q

codeine indcations

A

cough (off label)

pain managment

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13
Q

US box warnings for codeine

A
  1. ultra rapid metabolism of codeine- life threatening respiratory depression has occurred. most cases after TONSILLECTOMY and or adenoidectomy. many had evidence of being ultra rapid metabolizer d/t CYP2D6 polymorphism
    1. cytochrome p450 3a4 inhibitors- coadministration may cause increased hydrocodone plasma
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14
Q

MOA of Codeine

A

cough suppressant by direct central action in the medulla

  • converted by CYP 2d6 into morphine
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15
Q

contraindications for codeine

A
  1. pediatrics <12 y/o
  2. post op pain management in peds <18 who have undergone tonsillectomy or adenoiodectomy
  3. concurrent MAOI administration or within the last 14 days
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16
Q

dextromethorphan indications

A

cough suppressant

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17
Q

MOA dextromethorphan

A

depresses the medullary cough center and interrupts cough impulse transmission (similar structure to codeine)

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18
Q

contraindications to dextromethorphan

A

concurrent administration with or w/in 2 weeks of an MAOI

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19
Q

ADR of dextromethorphan

A
  1. euphoria - similar to ecstasy/ alcohol intoxication and at higher doses - ketamine - intense hallucinations
    1. drowsiness, dizziness, restlessness
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20
Q

Benzonatate indications

A

cough suppressant

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21
Q

Benzonatate MOA

A

topical anesthetic action suppresses cough by action on the respiratory stretch receptors

22
Q

ADRs of benzonatate

A
  1. sedation/ dizziness
  2. constipation
  3. OD: seizures, arrhythmias, death (especially in small children)
    1. bronchospasm if capsules are opened
23
Q

Antihistamines - diphenhydramine, promethazine, dooxylamine

indications

A

cough suppressant, many others

24
Q

MOA of Antihistamines - diphenhydramine, promethazine, dooxylamine

A

histamine 1 antagonist- located in respiratory tract and in brain- unsure of the exact mechanism

25
Q

ADR of Antihistamines - diphenhydramine, promethazine, dooxylamine

A
  1. anticholinergic effects- dry mouth, urinary retention
    1. drowsiness, sedation
26
Q

expectorants

A

drugs that render COUGHING MORE PRODUCTIVE by stimulating the flow of the respiratory tract secretions

  • one agent- guafenesin- seems to be the only expectorant that has clinical efficacy
27
Q

Guaifenesin indications

A

expectorant

28
Q

COPD Exacerbation

A

An acute event characterized by worsening of respiratory symptoms beyond normal day-to-day variations

  • often leads to at least a temporary change in medications- may be a permanent change
29
Q

Acute changes in cardinal symptoms of COPD Exacerbations

A
  1. Cough increase in frequency and/or severity
  2. sputum production increases in volume and/ or changes character
  3. dyspnea increases
30
Q

Why would a COPD Exacerbation lead to hospitalization

A
  1. inadequate response to outpatient/ ED treatment
  2. troublesome signs- cyanosis, altered mental status, peripheral edema
  3. serious comorbidities- pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/hepatic failure
  4. frailty or insufficient home support
31
Q

Home management of COPD

A
  1. Ensure access to an inhaled short acting bronchodilator, with preference to a SABA
    1. often times patients will require a short term titration up in dosing from 2 puffs q4-6 hours to 2 puffs q1-2 hours for a day or two
    2. if having a severe exacerbation, it is likely more appropriate to use a nebulizer- more drug absorption and ease of administration
    3. combo therapy is slightly more effective than either SABA alone
  2. Continue use of LAMA/ LABA/ ICS
  3. Consider systemic glucocorticoid administration - less likely to return to ED or their children within 30 days
    1. prednisone - 40 mg daily for 5-14 days
    2. short term glucocorticoid administration (up to 3 weeks), even at fairly high doses, do not need to be tapered
  4. Antibiotics- use only in those who are likely to have bacterial infection- increased cough or purulence
    1. mirrors antibiotic choices for pneumonia treatments
    2. azithromycin (and other macrolides) particularly beneficial with COPD exacerbations
  5. Antiviral- may initiate oseltamivir (tamiflu) for influenza positive patients
    1. COVID antivirals?
32
Q

Prednisone indications

A

Anti-inflammatory or immunosuppressant agent in the treatment of various diseases

33
Q

MOA of Prednisone

A

Anti-inflammatory - suppress migration of polymorphonuclear leukocytes and reversal of increased capillary permeability

34
Q

Contraindications Prednisone

A

Only a/w long term use- administration of live vaccines and systemic fungal infections

35
Q

ADRs of Prednisone

A

Lots- but mostly a/w long term use-

Short term- agitation, aggression, hunger, insomnia, energy boost

36
Q

Azithromycin Indications

A
  1. Acute COPD Exacerbation and many others (GP, GN, Atypicals- NO MRSA or Pseudomonas)
37
Q

MOA of Azithromycin

A
  1. inhibits bacterial protein synthesis
    1. exert anti-inflammatory effects by attenuated mucus secretion and decreased accumulation of PMN and MO in the airways- reduces inflammatory cytokine production
38
Q

Contraindications Azithromycin

A

History of cholestatic jaundice/ hepatic dysfunction a/w prior azithromycin use

39
Q

ADR of azithromycin

A

QT prolongation- increased risk of fatal heart rhythm

40
Q

Oseltamivir Indications

A
  1. Prophylaxis and treatment of influenza A or B
    1. dosing must begin no later than 2 days after symptom onset
    2. when started within 12 hours, symptom duration is reduced by 3 days, at 24 hours it is only reduced 2 days, and when started at 36 hours it is only reduced by 1.2 days
41
Q

MOA of Oseltamivir

A

Inhibits virus neuraminidase- enzyme responsible foor cleaving budding viral progeny- prevents additional viruses from being released

42
Q

ADR of Oseltamivir

A

GI Disturbances

43
Q

How to treat a COPD exacerbation in the hospital

A
  1. reversing airflow limitation with short acting bronchodilator- typically nebulized
  2. systemic glucocorticoids
  3. treat any underlying infections
  4. sometimes nicotine replacement
  5. VTE prophylaxis
44
Q

Short acting bronchodilators - copd exacerbation

A

Should be nebulized

  • continuous albuterol (10mg/ hr) inhalation- followed by 1 neb (2.5 mg) q2-4 hours prn
  • albuterol/ ipratropium - dual effects with SABA/ SAMA
  • continue LABAs/LAMAs/ ICS during exacerbation
45
Q

Systemic glucocorticoids for COPD exacerbations

A
  1. methylprednisolone is often used in hospital treatments
  2. same duration as office/ at home treatment- 5-14 days
46
Q

Treating underlying infections for COPD exacerbation

A
  • similar to at home/ in office treatment- pneumonia antibiotics for suspected bacterial and oseltamivir for positive influenza
  • start COVID meds if covid +
47
Q

Nicotine Replacement for COPD exacerbation

A

reduce symptoms of withdrawal- typically done with nicotine patches unless a patient comes in on bupropion or varenicline

48
Q

VTE prophylaxis for COPD exacerbation

A

enoxaparin 40 mg daily (30 mg for kidney dysfunction) or heparin 5000 units subq q8- q12 h (7500 units in morbidly obese)

49
Q

Methylpredinsolone indications

A

similar to prednisone- many anti-inflammatory condiitions

50
Q

Methyloprednisolone contraindications

A

Same as predisoone

51
Q

Routes of methylprednisolone

A
  1. iv route- 125 mg ONCE then 40-60 mg q6-12 hours
  2. Oral tabs - Medrol dose pack
52
Q

Methylprednisolone ADR

A

same as prednisone for short and long term ADR

Exam 2- Practical Therapeutics (10 decks)

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