COPD exacerbation Flashcards
Mucolytics function
- which drugs are mucolytics
- how are they administered
- what ADR can they cause?
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
Acetylcysteine indications
mucolytic, acetaminophen OD
Acetylcysteine MOA
lowers mucus viscosity allowing for more productive cough
acetylcysteine routes CAUTION
- nebulized inhalation
- oral tabs, IV (Acetaminophen OD)
acetylcysteine adr
bronchospasm
hypertonic saline indications
mucolytic
MOA of hypertonic saline
restores moisture to pulmonary system and allows for more productive cough
Route hypertonic saline
Nebulized inhalation preferred
ADR hypertonic saline
bronchospasm
Cough suppressants
- what does coughing involve?
- how is coughing initiated?
- what is cough beneficial for?
- when should a cough be suppressed?
- 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
Antitussive drugs
- suppress cough but do NOT treat the underlying condition
- opioid antitussives-
- codeine
- non- opioid antitussives
- benzonotate
- antihistamines ( prromethazine, diphenhydramine)
- dextromethorphan
codeine indcations
cough (off label)
pain managment
US box warnings for codeine
- 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
- cytochrome p450 3a4 inhibitors- coadministration may cause increased hydrocodone plasma
MOA of Codeine
cough suppressant by direct central action in the medulla
- converted by CYP 2d6 into morphine
contraindications for codeine
- pediatrics <12 y/o
- post op pain management in peds <18 who have undergone tonsillectomy or adenoiodectomy
- concurrent MAOI administration or within the last 14 days
dextromethorphan indications
cough suppressant
MOA dextromethorphan
depresses the medullary cough center and interrupts cough impulse transmission (similar structure to codeine)
contraindications to dextromethorphan
concurrent administration with or w/in 2 weeks of an MAOI
ADR of dextromethorphan
- euphoria - similar to ecstasy/ alcohol intoxication and at higher doses - ketamine - intense hallucinations
- drowsiness, dizziness, restlessness
Benzonatate indications
cough suppressant
Benzonatate MOA
topical anesthetic action suppresses cough by action on the respiratory stretch receptors
ADRs of benzonatate
- sedation/ dizziness
- constipation
- OD: seizures, arrhythmias, death (especially in small children)
- bronchospasm if capsules are opened
Antihistamines - diphenhydramine, promethazine, dooxylamine
indications
cough suppressant, many others
MOA of Antihistamines - diphenhydramine, promethazine, dooxylamine
histamine 1 antagonist- located in respiratory tract and in brain- unsure of the exact mechanism
ADR of Antihistamines - diphenhydramine, promethazine, dooxylamine
- anticholinergic effects- dry mouth, urinary retention
- drowsiness, sedation
expectorants
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
Guaifenesin indications
expectorant
COPD Exacerbation
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
Acute changes in cardinal symptoms of COPD Exacerbations
- Cough increase in frequency and/or severity
- sputum production increases in volume and/ or changes character
- dyspnea increases
Why would a COPD Exacerbation lead to hospitalization
- inadequate response to outpatient/ ED treatment
- troublesome signs- cyanosis, altered mental status, peripheral edema
- serious comorbidities- pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/hepatic failure
- frailty or insufficient home support
Home management of COPD
- Ensure access to an inhaled short acting bronchodilator, with preference to a SABA
- 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
- if having a severe exacerbation, it is likely more appropriate to use a nebulizer- more drug absorption and ease of administration
- combo therapy is slightly more effective than either SABA alone
- Continue use of LAMA/ LABA/ ICS
- Consider systemic glucocorticoid administration - less likely to return to ED or their children within 30 days
- prednisone - 40 mg daily for 5-14 days
- short term glucocorticoid administration (up to 3 weeks), even at fairly high doses, do not need to be tapered
- Antibiotics- use only in those who are likely to have bacterial infection- increased cough or purulence
- mirrors antibiotic choices for pneumonia treatments
- azithromycin (and other macrolides) particularly beneficial with COPD exacerbations
- Antiviral- may initiate oseltamivir (tamiflu) for influenza positive patients
- COVID antivirals?
Prednisone indications
Anti-inflammatory or immunosuppressant agent in the treatment of various diseases
MOA of Prednisone
Anti-inflammatory - suppress migration of polymorphonuclear leukocytes and reversal of increased capillary permeability
Contraindications Prednisone
Only a/w long term use- administration of live vaccines and systemic fungal infections
ADRs of Prednisone
Lots- but mostly a/w long term use-
Short term- agitation, aggression, hunger, insomnia, energy boost
Azithromycin Indications
- Acute COPD Exacerbation and many others (GP, GN, Atypicals- NO MRSA or Pseudomonas)
MOA of Azithromycin
- inhibits bacterial protein synthesis
- exert anti-inflammatory effects by attenuated mucus secretion and decreased accumulation of PMN and MO in the airways- reduces inflammatory cytokine production
Contraindications Azithromycin
History of cholestatic jaundice/ hepatic dysfunction a/w prior azithromycin use
ADR of azithromycin
QT prolongation- increased risk of fatal heart rhythm
Oseltamivir Indications
- Prophylaxis and treatment of influenza A or B
- dosing must begin no later than 2 days after symptom onset
- 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
MOA of Oseltamivir
Inhibits virus neuraminidase- enzyme responsible foor cleaving budding viral progeny- prevents additional viruses from being released
ADR of Oseltamivir
GI Disturbances
How to treat a COPD exacerbation in the hospital
- reversing airflow limitation with short acting bronchodilator- typically nebulized
- systemic glucocorticoids
- treat any underlying infections
- sometimes nicotine replacement
- VTE prophylaxis
Short acting bronchodilators - copd exacerbation
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
Systemic glucocorticoids for COPD exacerbations
- methylprednisolone is often used in hospital treatments
- same duration as office/ at home treatment- 5-14 days
Treating underlying infections for COPD exacerbation
- similar to at home/ in office treatment- pneumonia antibiotics for suspected bacterial and oseltamivir for positive influenza
- start COVID meds if covid +
Nicotine Replacement for COPD exacerbation
reduce symptoms of withdrawal- typically done with nicotine patches unless a patient comes in on bupropion or varenicline
VTE prophylaxis for COPD exacerbation
enoxaparin 40 mg daily (30 mg for kidney dysfunction) or heparin 5000 units subq q8- q12 h (7500 units in morbidly obese)
Methylpredinsolone indications
similar to prednisone- many anti-inflammatory condiitions
Methyloprednisolone contraindications
Same as predisoone
Routes of methylprednisolone
- iv route- 125 mg ONCE then 40-60 mg q6-12 hours
- Oral tabs - Medrol dose pack
Methylprednisolone ADR
same as prednisone for short and long term ADR
