Day 5- Intro to pulmonology and asthma and allergic rhinitis

Question 1

What is tidal volume?

What is vital capacity?

What is residual volume?

Answer 1

Volume of air inspired or expired during normal breathing.

Volume of air blown off after maximal inspiration to full expiration.

Volume of air left after a maximal expiration.

Question 2

What is functional residual capacity?

What’s the biggest component of asthma?

What is severity vs control in asthma?

Answer 2

Volume of air left after a normal expiration.

Airway inflammation.

Severity is the intrinsic intensity of the disease process. Control is the degree to which the manifestations of asthma are minimized and the goals of therapy are met.

Question 3

What is your gold standard in asthma diagnosing?

What are your peak flow meter zones?

What are your goals of therapy with impairment?

Answer 3

Spirometry, FEV1.

Green is 80-100% of personal best, Yellow is 50-79% of the personal best, Red is <50% of personal best. Do 3 times and record the best of the 3.

Require infrequent(<2days/week) of SABA, maintain normal activity levels.

Question 4

What are your goals of therapy for risk?

What are your quick relief medications for asthma?

What are your SABA agents to know?

Answer 4

Prevent lung loss function and exacerbation, provide optimal pharmacotherapy.

SABA’s, Anticholinergics.

Fenoterol, Levabuterol(xopenex), Albuterol(proair, proventil, ventolin), Pirbuterol.

Question 5

What are the 2 LABA single agents approved for asthma?

How do the SABA’s and LABA’s work?

When is SABA indicated?

Answer 5

Salmeterol, Formeterol.

Stimulate B2 receptors–>activates Gs pathway–> bronchodilation. Also increases conduction of Ca2 sensitive K channels in airway smooth muscle causing membrane hyperpolarization and relaxation.

Exercise induced bronchospasms, Asthma exacerbations.

Question 6

What are your A/E’s of beta 2 agonists?

What is LABA’s BBW?

What are your 3 systemic coricosteroids?

Answer 6

Tremor, weakness, arrythmia, rhinitis, hypokalemia, throat irritation.

Increase the risk of asthma related death(SMART trial showed this, worse in African Americans).

Prednisone, Prednisolone, Methylprednisolone.

Question 7

What are steroids MOA?

What is ICS main indication?

What is your anticholinergics MOA?

Answer 7

Interfere with activation and migration of inflammatory cells, interferes with arachidonic acid metabolism and synthesis of leukotrienes, reduces airway hyperresponsiveness, reveres B2 receptor downregulation, inhibit microvascular leakage.

Maintenance of asthma control. Only use systemic for short term use or asthma exacerbations.

blocks acetylcholine at parasympathetic sites causing bronchodilation

Question 8

What is the only anticholinergic that can be used for asthma?

What are your leukotriene modifiers?

What is your mast cell stabilizer?

Answer 8

Ipratropium.

Montelukast, Zafirlukast work on receptors. Zileuton is 5-lipoxygenase inhibitor and stops formation of leukotrienes.

Cromolyn. Prevents mast cell release–> tastes bad, cough, URTI.

Question 9

What are your methylxanthines?

What to know about monitoring theophylline?

What’s your anti- IgE- monoclonal antibody?

Answer 9

Theophylline, Aminophylline.

Very narrow index–> 5-15 ug/mL. Clearance is age dependent.

Omalizumab, dosed every 2-4 weeks based on IgE levels and weight. FDA approved for moderate to severe asthma not well controlled on steroids.

Question 10

What are your other severe asthma drug injectors?

When do you use severity tables?

What is mild intermittent asthma severity classification?

Answer 10

Resizulimab, Benralizumab, Mepolizumab.

First diagnosed or NOT on long term medication.

Symptoms <2 days per week, <2 nights per month of night time, no interference with normal, >80% FEV1.

Question 11

What is mild persistent asthma severity classification?

What about moderate vs severe classification?

Answer 11

> 2 days/week but <1x/day, 3-4x/month nighttime, minor limitation, >80% FEV1.

Severe is throughout the day, often 7x/week, extremely limited, <60%. 60-80% is moderate, some limitation. >1 night per week but not nightly, daily.

Question 12

What is mild intermittent treatment?

What is mild persistent(step 2) treatment?

What is step 3 treatment(moderate persistent)?

Answer 12

Step 1–> no daily medications, can use SABA.

Low dose inhaled corticosteroids.

(Low dose ICS + LABA) or medium dose ICS.

Question 13

What is step 4 treatment?

What is step 5 treatment?

What is step 6 treatment?

Answer 13

Medium dose ICS + LABA

High dose ICS + LABA

High dose ICS + LABA + Oral corticosteroids. Use omalizumab for patients with allergy in step 6.

Question 14

When is a patient well controlled?

When is a patient very poorly controlled?

What to do when a patient is well controlled?

Answer 14

<2 days per week symptoms, <2x/month night time, no interference, <2days per week SABA, >80% FEV1.

Symptoms throughout the day, >4times per week night time, extremely limited interference, several times per day SABA use, <60% FEV1.

Maintain current step, regular follow ups q1-6 months, consider step down if well controlled for at LEAST 3 months.

Question 15

What to do when a patient is not well controlled?

What to do when a patient is very poorly controlled?

What are your ICS’s?

Answer 15

Step up 1 step, Reevaluate in 2-6 weeks, for side effects, consider alternative therapies.

Consider short course of oral CS, step up 1-2 steps, reevaluate in 2 weeks, for side effects consider alternative therapies.

Budesonide, Fluticasone, Mometasone.

Question 16

What is hospital management of severe asthma exacerbation?

What is outpatient community acquired pneumonia management w/ no risk factors vs w/ risk factors?

What is Inpatient floor CAP treatment vs ICU?

Answer 16

if peak flow is <40%, or send to ICU you need to intubate. Everybody gets oxygen, bronchodilators, mild is +/- systemic, moderate or severe get one.

Macrolide, Macrolide + Betalactam or FQ.

Macrolide + Betalactam or FQ. Beta Lactam + Macrolide or FQ.

Question 17

What are some Allergic Rhinitis risk factors?

What causes acute rhinitis?

What are the types of AR?

Answer 17

Family history of atopy, higher socioeconomic class, heavy exposure to secondhand smoke, high IgE 11 uL> 6 years.

infectious, hormones, drugs, foreign bodies.

Allergic Rhinitis is hay fever, seasonal, usually predictable(pollen, grasses, weeds). Perennial allergic rhinitis–> may experience year around, house dust mites, animal dander.

Question 18

What’s the cut off for intermittent vs persistent AR and moderate/severe AR?

What are your 1st generation antihistamines?

What are your 2nd generation antihistamines?

Answer 18

Intermittent is <4 days or for < 4 consecutive weeks. Persistent is > or equal to 4 days a week and for > or equal to 4 weeks. Sleep disturbance, impairment of activities, troublesome symptoms.

Clorpheniramine, Clemastine, Diphenhydramine, Brompheniramine.

Non sedating–> Fexofenadine(allegra), loratadine(claritin,alavert), desloratadine(calranex). Mild Sedating–> Cetirizine(zyrtec), Levocitirizine(xyzal).

Question 19

What are your antihistamine A/E’s?

What are your intranasal corticosteroids to know?

Why can you not use topical products for more than 72 hours?

Answer 19

Sedation(1st gen), dry mucus membranes, headache, local irritation(topical), taste disturbance(azelastine).

Budenoside(rhinocort), Fluticasone(flonase allergy relief), mometasone(nasonex), Triamcinolone(nasacort).

Rhinitis medicamentosa.

Question 20

Do ocular formulations have a slow onset?

Does ipratropium only treat runny nose symptoms?

What are your immunotherapy products?

Answer 20

YES

YES

Oralair, Grastek, Ragwitek, Odactra

Question 21

Do oral antihistamines treat Nasal Congestion?

What treats nasal congestion?

Does immunotherapy help NI and NC?

Answer 21

NO

Decongestants, IN corticosteroids, leukotriene modifiers, nasal spray.

NO.

Question 22

How do you treat moderate to severe persistent symptoms?

What is in Advair? What about Breo?

What is in Symbicort? What about Dulera?

Answer 22

Intranasal CS preferred. Then H1 blocker or LTRA.

Salmeterol/Fluticasone. Vilanterol/Fluticasone.

Budesonide and Formoterol. Formoterol/ Mometasone.

Question 23

What drugs can treat allergic conjuctivitis?

Answer 23

Oral H1 blocker, Intraocular H1 blockers, Intraocular Cromone, Saline.