Exam 1: Asthma and COPD thangs Flashcards
What are some asthma triggers
-viral respiratory infections
-allergens (pollen, fungal)
-food allergy
-air pollution
-seasonal changes (return to school)
-por adherence to ICS
what are factors that increase asthma-related death?
-hx of asthma requiring intubation and mechanical ventilation
-hospitalization or ED visit within 1 yr
-currently using (or recently using) oral corticosteroids
-not currently using inhaled corticosteroids
-over-use of SABAS: > 1 albuterol canister/month
-Psychiatric or psychosocial problems, food allergies
-poor adherence with ICS asthma medications or written asthma action plan
-comorbidities: pneumonia, diabetes, arrhythmias, after hospitalization for an asthma exacerbation
How to treat an acute asthma exacerbation?
1) SABA (Preferred: albuterol)
1) systemic corticosteroids (Prednisone)
1) oxygen: titrate O2 saturation of 94-98%
optional
-Ipratropium
-Magnesium
-ICS
SABA use in acute asthma tx
-MDI: 4-8 puffs every 30 mins up to 4 hours, then every 1-4 hours as needed
-Neb: 2.5-5mg every 20 mins x 3 doses, then every 1-4 hours as needed (titrate to response0
-SABA > IPRATROPIUM
-inhaled + spacer = neb
-dose dependent
-durations: 2-4 hours
Systemic Corticosteroid use in acute asthma tx
-Dose: 50 mg po daily for 5-7 days (prednisone)
-PO preferred unless vomiting, intubated, somnolence
-onset: 4 hours until improvement
Ipratropium use in acute asthma tx
optional
MDI: 8 puffs every 20 mins as needed up to 3 hours
Neb: 500 mcg every 30 mins x 3 doses, and then every 2-4 hours as needed
ED ONLY! –> in combo with a SABA showed fewer hospitalizations and improvement in PEF/FEV1, dose dependent
Magnesium in acute ashtma tx
-2mg IV x 1 (IF NOTHING ELSE IS WORKING)
-ED ONLY! failure to respond to initial treatment or have persistent hypoxemia, FEV1 < 25-30%
ICS use in acute asthma tx
-high dose ICS within 1 hr
-in the ED only! can reduce the need for admission if systemic steroids are not given
-if admitted, should be started on or continued
should be given on discharge home
Treatment of acute exacerbation on discharge
1) inhaled ICS: if not on, ADD ICD. If on, increase (step-up) the dose for 2-4 weeks
2) oral corticosteroids (OCS): 5-7 day total dose; re-evaluation should
what medications can you NOT use in asthma tx?
-aminophyline/theophyline
-leukotriene receptor antagonists
-hydration
-high-dose mucolytics
-antihistamines
-chest physiotherapy
-sedation
-antibiotics
medication efficacy/toxicity in acute asthma
-steroids: WBC, glucose (daily, could become hyperglycemic)–> consider short acting insulin if needed
-bronchodilators: HR, frequency of use (want them to get to PRN dosing)
Predisposing factors & allergens of allergic rhinitis
PFs: fam hx of allergic rhinitis, atopic dermatitis/eczema or asthma, allergen exposure, heavy exposure to secondhand smoke
Allergens: pollen grains, mold spores, dust mite fecal proteins, animal dander, cockroaches
Clinical presentations of allergic rhinitis
-clear rhinorrhea
-sneezing
-nasal congestion
-postnasal drip
-itchy eyes, ears, nose, or palate
-malise/fatigue
-pale or bluish discoloration and swelling of nasal mucosa
-conjunctivitis/watery ocular discharge
Mild Intermittent classification of AR
< 4 days per week OR < 4 weeks per year with NO interference with QOL
Moderate to severe intermittent classification of AR
< 4 days per week OR < 4 weeks per year with interference with QOL
Mild persistent classification of AR
> 4 days per week AND > 4 weeks per year with NO interference with QOL
Moderate to severe persistent classification of AR
> 4 days per week AND > 4 weeks per year with interference with QOL
Nonpharmacologic options for AR treatment
-nasal saline irrigations: improves nasal symptoms and reduce need for medications, well-tolerated and safe
-adhesive nasal strips: facilitate breathing and reduce nasal obstruction
Intranasal Corticosteroids for tx of AR (facts)
-reduce inflammation
-treat: congestion, rhinorrhea, sneezing, nasal itching, ocular symptoms
-onset ranges from 3-5 hrs to 36 hrs after first dose, assume efficacy should be reached after 1 week of continuous use
SEs: headache, dryness, burning, stinging, blood-tinged secretions and epistaxis *avoid use in those with nasal septum ulcers, recent nasal surgery or trauma
Intranasal Corticosteroids for tx of AR (drugs)
beclomethasone
budesonide
flunisolide
fluticasone propionate
fluticasone furoate
mometasone
triamcinolone
ciclesonide
Oral Antihistamine use for TX of AR (facts)
-most effective when administered prior to allergen exposure
1st gen: lipophilic, cross BBB, anticholinergic effects and excessive sedation
2nd gen: highly selective for H1 receptor, limited penetrations into CNS
–> treats: rhinorrhea, sneezing, nasal itching, ocular symptoms
SEs: sedation, anticholinergic side effects, changes in appetite and GI discomfort
–> caution with: elderly pts, use with other CNS depressants, urinary retentions issues, slowed GI motility, narrow angle glaucoma
Oral antihistamines used in tx of AR (drugs)
1st gen: chlorpheniramine, diphenhydramine
2nd gen: cetirizine, levocetirizine, loratadine, desloratadine, fexofenadine
Intranasal antihistamines used in tx of AR
-rapid onset 15-30 mins
–> treats: congestion, rhinorrhea, sneezing, nasal itching
SEs: bitter taste, epistaxis, headache, somnolence and nasal burning (taste and BID dosing may limit adherence)
Drugs: azelastine, olopatadine, azelastine/fluticasone
Ophthalmic antihistamines used in tx of AR
-relieves allergic conjunctivitis (ocular symptoms)
-appropriate as mono therapy or in combination with oral agents
SEs: headache, blurred vision, burning/stinging of the eyes, discomfort, bitter taste, pharyngitis
Drugs: ketotifen, azelastine, olopatadine, alcaftdadine, emedastine, epinastine
Topical Decongestants in tx of AR
-applied directly to the nasal mucosa, rapid onset of action
-prolonged use for more than 3-5 days may result in rhinitis medicamentosa
SEs: sneezing, burning, stinging, drying of nasal mucosa
Drugs: phenylephrine, tetrahydrozoline, naphazoline, oxymetazoline
Oral Decongestants in tx of AR
-slower onset than topical decongestants
SEs: increases in blood pressure (avoid use with MAOIs- risk for significant hypertension), CNS stimulation, urinary retention
Drugs: pseudoephedrine, phenylephrine, ceterizine/pesud, loratadine/pseudo, fexofenadine/psuedo
Cromolyn in TX of AR
-useful for treating and preventing sinus symptoms (runny nose, stuffy nose, sneezing and itching)
used in pregos and breast feeding pts
SEs: sneezing and nasal irritation
-1 spray in each nostril 3-4 times daily, slow onset of action
Ipratropium in TX of AR
-treats rhinorrhea
-SEs: headache, nosebleeds and nasal dryness. caution in use with narrow-angle glaucoma, myasthenia gravis, and bladder neck obstructions/BPH
Montelukast in tx of AR
-treat symptoms of perennial and seasonal allergic rhinitis
SEs: headache, fatigue, GI upset, nasal congestion, neuropsychiatric events
-slower onset, may not achieve full effect until after a month of use
Omalizumab in tx of AR
-limited use: approved for tx of allergic asthma, risk of anaphylaxis, malignancy, acute asthma attacks, serum sickness
*last line therapy: typically requires specialist input prior to receiving treatment
Asthma
asthma is characterized by either the intermittent or persistent presence of highly variable degrees of airflow obstruction from airway wall inflammation and bronchial smooth muscle constriction and in some pts, persistent changes in airway structure occur
symptoms associated with variable expiratory flow could be due to:
-bronchoconstriction
-airway wall thickening
-increased mucus
where is asthma prevalent:
-increasing in industrialized countries
-higher in persons with low income
-higher in black persons/persons of multiple races
(AAs > whites > hispanic)
Increased risk of asthma can be attributed to:
-higher exposure to residential allergens
-shortage of PCPs in minotriy. communities
-socioeconomic disparities
-language and literacy barriers
-underuse of asthma medications
–> most evidence seems to point towards socioeconomic and environmental disparities, behavioral or cultural differences, and less access to routine health care
environmental risk factors attributed to asthma
-socioeconomic status
-exposure to second-hand tobacco smoke in infancy/ in utero
-allergen exposure
-urbanization
-RVS infection
-family size
-decreased exposure to common childhood infectious agents
Clinical Symptoms of asthma
-dyspnea
-chest tightness
-coughing
-wheezing or whistling sound when breathing
-may occur in association with exercise, laughter, cold air, with allergen exposure or spontaneously
Clinical signs of asthma
-expiratory wheezing on auscultation
-dry, hacking cough
-signs of atopy (AR or eczema)
-reduced O2 saturation (normal is 94% +)
more likely to be asthma if…
- more than 1 type of symptoms (wheeze, SOB, cough, chest tightness)
-symptoms often worse at night or in the early AM
-symptoms VARY over time and in intensity
-symptoms have identifiable triggers
less likely to be asthma if…
-chronic production of sputum
-isolated cough with no other respiratory symptoms
-SOB is associated with dizziness, lightheadedness or peripheral tingling
-chest pain
-exercise-induced dyspnea with stridor
Short acting beta 2 agonists (SABAs) in asthma tx
RESCUE THERAPY ONLY!
-causes relaxation of bronchial smooth muscle resulting in bronchodilation
-SEs: tremor, shakiness, lightheadedness, cough, palpitations, hypokalemia, tachycardia, hyperglycemia
Albuterol (SABA)
MDI: ProAir HFA, Proventil HFA, Ventolin HFA, ReliOn Ventolin HFA
DPI: ProAir RespiClick
SOB/rescue: 2 puffs Q 4-6 hrs
EIB: 2 puffs 5-20 mins prior to exercise
Levalbuterol (SABA)
-R-isomer of albuterol
Pressurized inhalation suspension: Xopenex HFA & neb solution
SOB/rescue: 2 puffs q 4-6 hr PRN
EIB: 2 puffs 10-30 mins before exercise
Inhaled corticosteroids (ICS) in asthma tx
-MAINTENANCE MED
–> most effective anti-inflammatory medication for persistent asthma
-reduce chronic airway inflammation, reduce risk of exacerbations, improved lung function, reduce symptoms & improve QOL
AEs: use the lowest dose possible (rec to decrease dose of ICS 25-50% after a 3 month stability period), growth concerns in young children (meh), hyperglycemia
**most common side effects are oropharyngeal candidiasis and dysphonia –> counsel pts to rinse mouth and spit after use
-avoid in acute bronchospasm and status asthmatics
-avoid DPIs in those with milk allergies (Budesonide is an exception)
Ciclesonide (Alvesco) ICS
-BID dosing
-not rec in children < 12
-activated in the lungs potentially reducing side effects caused by ICS in the lung and throat –> may be goos alt for pts who experience frequent thrush/hoarseness from other ICS
-do not need to shake before use
Fluticasone (ICS)
–> Flovent Diskus ot HFA: not rec in children <4, shake HFA before use
–> Arnuity Ellipta: QD dosing, not rec in children < 12
–> ArmonAir RespiClick: BID dosing, not rec ofr children < 12
**higher risk of sore throat/hoarseness compared to other ICS
Beclomethasone (Qvar RediHaler) ICS
-BID dosing
-do not need to shake before use
-not rec in children < 5
-smaller inhaled particles lead to better lung penetration when compared to other ICS
Monetasone (Asmanex) ICS
-QD-BID dosing
-not rec in children < 4
-Twisthaler good for 45 days after removed from foil package
-QD dosing- administer in the evening
Budensonide (Pulmicort) ICS
-DPI & neb
-QD-BID dosing
-neb solution preferred ICS in children < 4
-DPI not rec in children < 6
Long-acting beta2 agonists (LABAs) in asthma
MAINTENANCE THERAPY (used in combo with ICS always!)
-formoterol/ICS combo now rec as PRN/reliever for asthma prevention and management
BBW: increased risk of asthma-related death
Budesonide/Formoterol (Symbicort) ICS/LABA
-MDI; 1-2 puffs BID,
-shake before using
-discard 3 months after removal from foil pouch
-also labeled for COPD
-may be used as a rescue therapy/PRN
ICS/LABA formulations:
-Fluticasone propionate/salmeterol (Advair/Wixela) ICS/LABA
-Fluticasone propionate/Salmeterol (AirCuo Respiclick)
-Fluticasone furoate/Vilanterol (Breo Ellipta)
-Mometasone/Formoterol (Dulera)
Long acting muscarinic antagonists (LAMAs) in asthma
MAINTENANCE THERAPY
-leads to bronchodilation
Tiopropium (Spirvia Respimat)
–> for pts > 12 y/o
-may be beneficial to add on for still-uncontrolled asthma in pts on a medium to high dose ICS + LABA
Leukotriene Antagonists in asthma tx
-maintenance medications for persistent asthma
-alternative therapy in step 2
-add on therapy in steps 3 and 4
Montelukast in asthma tx
-EIB: 10 mg taken 2 hours before exercise, no more than once q24 hrs
-ADR: headache, upper respiratory tract infections, GI side effects, can also cause psychiatric changes
Zafirlukast (accolate) for asthma TX
-only FDA indicated for asthma
-20 mg BID, take on an empty stomach 1 hr before or 2 hrs after meals
-CI in hepatic impairment, no renal dose adjustment needed
ADR: headache, liver failure, neuropsychiatric symptoms
DDI: warfarin, aripiprazole, theophylline
Zileuton (Zyflo) for asthma tx
-only FDA indicated for asthma
- 2 tabs BID one hour before morning and evening meals –> not for children < 12
-CR tabs: do not crush, break or chew
ADR: N/V/D, headache, hepatotoxicity, neuropsychiatric symptoms
DDI: theophylline, ramelteon, ergot alkaloids
Theophylline use in asthma TX
-not used as often
-caution in pts with CVD, hyperthyroidism, PUD, and seizures
Side effects: nausea, loose stools, headache, tachycardia, insomnia, tremor, nervousness
prego catergory C
Serum target = 5-15 mcg/ml
Biologic Therapies in asthma tx
-add on therapy in step 5 for pts with severe allergic or eosinophilic asthma (reduce exacerbation rate by ~50% & steriod-sparing effect)
Drugs: Omalizumab, Mepolizumab, Reslizumab, Benralizumab, Dupilumab
Cromolyn in chronic asthma tx
-mast cell stabilizer
-alternative therapy for step 2, not rec for routine use
-also used for EIB prophylaxis in pts who still have symptoms w/ SABA
OTC Epinephrine in chronic asthma tx
Asthmanerfrin
-dont use it, can cause a lot of cardio effects
Systemic Corticosteriods in chronic asthma tx
-Glucocorticoids: use in severe asthma, improve receptor responsiveness to beta 2 adrenergic stimulation, reduce mucus production and hyper-secretion, decrease BHR, reduce airway edema
-systemic side effects vs ICS: hyperglycemia, increased appetite/weight gain, insomnia/nervousness, osteoporosis/fractures, growth retardation, immunosuppression, HPA axis. suppression
–> Prednisone & methylprednisone
GINA assessment of symptom control (qs and classification)
-daytime asthma symptoms more than twice a week?
-any night waking due to asthma?
-reliever (SABA) for symptoms more than twice/week?
-any activity limitation due to asthma?
Well controlled: 0
Partly controlled: 1-2
Uncontrolled: 3-4
Risk factors for poor asthma outcomes
-exacerbations, fixed airflow limitation & medication side effects
-Medications: ICS not prescribed, poor adherence, incorrect inhaler technique, high SABA use
Risk factors for developing fixed airflow limitations
-preterm brith/ low birth weight
-lack of ICS treatment
-exposure to tobacco smoke, noxious chemicals, or occupational exposures, low FEV1, chronic mucus hyper-secretion, sputum or blood eosinophilia
Risk factors for medication side effects
Systemic: frequent oral CS, long-term, high-dose and/or potent ICS, also taking P450 inhibitors
Local: high-dose or potent ICS, poor inhaler technique
Stepping down asthma therapy
-good asthma control achieved and maintained for > 3 months
-reduce ICS dose by 25-50 % at 2-3 month intervals
*do not completely stop ICS unless needed temporarily to confirm diagnosis
Exercise-induced Brinchospasm (EIB)
-a drop in FEV1 of 15% or more from baseline (pre-exercise)
-should be anticipated in ALL asthma pts, but especially those with asthma symptoms during exercise or endurance problems
-pre-treatment with SABA is most common (ICS/formoterol can be used)
-
tx on discharge after acute asthma exacerbation
-inhaled ICS (if not on, add. if on - increase dose for 2-4 weeks
-oral corticosteroid: 5-7 days total
-reliever (ICS PRN or SABA) - transition pt back to an as needed for outpatient
Meds NOT to use in acute asthma exacerbation tx
-aminophylline/theophylline
-leukotriene receptor antagonists
-hydration
-high-dose mucolytics
-antihistamines
-chest physiotherapy
-sedation
-antibiotics
COPD def
common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gasses.
Risk factors for COPD
1: cig smoking
-occupational dust and chemicals
-environmental tobacco smoke
-indoor and outdoor air pollution
-genes (alpha-1 antitrypsin deficiency)
-infections 9HX of severe childhood resp infections)
-socio-economic status
-AGING populations
Clinical Presentation of COPD
-dyspnea; progressive, persistent and characteristically worse with exercise
-cough; often 1st symptom of COPD
-chronic sputum production
-wheezing
-comorbidities: depression, anxiety, ankle swelling, weight loss, fatigue, rib fractures
KEY indicators for considering a diagnosis of COPD
-dyspnea
-chronic cough
-chronic sputum production
-recurrent lower respiratory tract infections
-hx of risk factors
-fam hx of COPD and/or childhood factors
Diagnosis of COPD
-spirometry: post-bronchodilator FEV1/FVC < 0.7
required to make diagnosis
-chest x-ray; used to rule out other things- may show lung hyperinflation, hyper lucency of the lungs
Bronchodilators in COPD tx
-mainstay of COPD therapy
-increases FEV1 –> change reflects widening of the airways rather than changes in lung elastic recoil
-improve emptying of the lungs –> decrease hyperinflation at rest and during exercise
-improves exercise performance
-relatively flat dose-response curve: toxicity is dose related
SABAs in COPD tx
-Albuterol: ProAir, Proventil HFA, Ventolin HFA, ProAir Respiclick
-Levalbuterol: Xopenex HFA
LABAs in COPD tx
-Salmeterol (Servent)
-Formoterol (Perforomist) –> Neb only
-Olodaterol (Striverdi Respimat)
-Aformoterol (Brovana) –> neb only
-Indacaterol (Arcapta)
Bronchodilators: muscarinic antagonists in COPD tx
-SAMAs have slightly longer duration of action than SABAs
-poor systemic absorption –> limits the anticholergic side effects
-ADRs: dry mouth, tiotropium may cause metallic taste, cough, nausea, blurred vision, reports of glaucoma with use of face mask
SAMAs in COPD tx
-Ipratropium Bromide (Atrovent HFA)
LAMAs in COPD tx
-Tiotropium (spiriva HandiHaler, Spirivia Respimat)
-Aclidinium (Tudorza Pressair)
-Umeclidinium (Incruse Ellipta)
-Glycopyrrolate (Seebri Neohaler)
-Glycopyrrolate (Lonhala Magnair)
-Revefenacin (Yupelri)
SABA + SAMA combinations in COPD tx
-improve efficiacy & equal or lesser side effects
-Albuterol/Ipratropium (combivent Respimat)
-Albuterol/ipratropium (DuoNeb)
LABA + LAMA combinations inCOPD tx
-indacaterol/Glycopyrrolate
-tiotropium/olodaterol
-umeclidinium/vilanterol
-glycopyrrolate/formoterol
-aclidinium/fomoterol
ICS/LABA combination products for tx in COPD
-NO ICS MONO THERAPY IN COPD
-fluticasone furoate/vilanterol
-fluticasone propionate/sameterol
-budesonide/fomoterol
-mometasone/formoterol
oral glucocosteriods in COPD tx
-role in tx of exacerbation
-NO role in the chronic daily management of COPD –> lack of benefit demonstrated and high risk of systemic complications
triple inhaler therapy in COPD
should NOT be your first line
-fluticasone furoate/umeclidinium/vilanterol
-budesonide/glycoptrrolate/formoterol
Roflumilast (Daliresp) tx in COPD
-reduced inflammation by inhibiting the breakdown of intracellular cAMP
-dose: 500 mcg PO QD
ADs: nausea, diarrhea, weight loss, sleep disturbances, headache, may worsen depression/associated with suicidal ideation
*do NOT use with theophylline
Assessment of Exacerbation Risk
-COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy
–> mild: treated with SABA only
–> moderate: treated with SABA + antibiotic and/or oral corticosteroids
–> severe: pt requires hospitalization or visits the ER. severe exacerbation may also be associated with acute respiratory failure
-blood eosinophil count may also predict exacerbation rates
Pt is HIGH exacerbation risk if:
-2 or more exacerbations in the last year
OR
-1 or more exacerbation in the last year that led to hospitalization
pt is NOT considered high exacerbation risk if:
-NO exacerbations in the last year
OR
-1 exacerbation in the last year that did NOT lead to hospitalization
COPD pts are at increased risk for:
-cardiovascular diseases (~30% have heart failure)
-osteoporosis
-respiratory infections
-anxiety and depression
-diabetes
-lung cancer
-bronchiectasis
ICS role in stable COPD tx
*if eosinophil count > 300 cells/uL and > 100 (+ exacerbations)
-long term use = increased risk of pneumonia
**asthma hx or features of asthma present –> ICS combo therapy indicated
Factors to consider when initiating ICS tx (strong support)
-hx of hospitalization for execrbations
-> 2 moderate exacerbations of COPD per year
-blood eosinophils > 300
-hx of or concomitant asthma
non-pharm management of COPD
**smoking cessation
-vaccinations (influenza, pneumococcal, Tdap, Covid)
-pulmonary rehabilitation (good for groups B +)
-long-term oxygen therapy
Asthma-COPD overlap
Persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. It is identified by the features that it shares with both asthma and COPD
Asthma-COPD overlap features
-usually > 40 years of age
-may have had symptoms in early childhood
-persistent airflow limitations, not fully reversible, and with variability
-often has hx of childhood asthma, allergies, exposure to smoke or other irritants or fam hx of asthma
-tx partially decreases symptoms
-chest X-ray similar to COPD
-exacerbations more common than in COPD alone
-eosinophils and/or neutrophils in sputum
-comorbidities may lead to further impairement
Acute COPD exacerbation
-acute worsening of respiratory symptoms that results in additional therapy or medications
Patho: increased airway inflammation, increased mucus production, increased mucus production, marked gas trapping & increased eosinophils in significant numbers of pts
Symptoms of acute COPD exacerbation
-increased dyspnea
-increased sputum purulence and volume
-increased cough and wheeze
*lasts about 7-10 days
Causes of acute COPD exacerbation
1: viral –> rhinovirus
#2: bacterial
#2: others: pollution, ambient temp, fine particle matter exposure
#3: fungal: very rare, Aspergillus ssp.
Labs to analyze in COPS exacerbation
-ABG, VBG
-WBC: viral/bacterial infections
-electrolytes: K, Mg, glucose
-vitamin D: if < 10 ng/ml or 25 nM = give supplement
-use sputum sample and chest x ray as a diagnostic tool
when to use noninvasive mechanical ventilation (NIV)
(nasal canula)
-uses pressurized air flow with O2 without intubation
-severe respiratory acidosis (pH < 7.35 and PaCO2 > 6k or 45 mmHg), severe dyspnea, persistent hypoxemia
When to use intubation and mechanical ventilation
-life-threatening hypoxemia, respiratory/cardiac arrest, hemodynamic instability, altered mental status, failed NIV, massive aspiration/persistent vomiting, severe ventricular or supraventicular arrhythmias
Bronchodilator use in acute COPD exacerbation
(SAMA + SABA)
-albuterol + ipratropium: 1 puff Q 1h x 2-3 doses then 2 puffs Q 2-4 hrs
Corticosteroid use in acute COPD exacerbation
Prednisone: 40 mg po daily
-treat for 5 days, use oral unless a pt cannot tolerate
Oxygen use in acute COPD exacerbation
titrate to goal of 88-92%
Antibiotic use in acute COPD exacerbation
-treat for 5-7 days IF pt is ill with 3 of these signs:
1) increased dyspnea
2) increased sputum volume
3) sputum purulence (only need 1 other with this)
OR on mechanical ventilation
Antibiotic drugs used in acute COPD exacerbation
bacteria: haemophilus influenzar, streptococcus pneumoniae, Moraxella Catarrhalis
–> Augmentin 875 mg po BID or Unasyn 3 mg IV Q 6 hr (both have renal elimination)
–> azithromycin 500 mg po daily x 3 days or 500mg X1, then 250mg days 2-5
–> doxycycline 100mg po BID
-if frequent exacerbations, severe airflow limitation or mechanical ventilation = need cultures
-at risk for Pseudomonas: cefepime, Piperacillin/Tazobactam, levofloxacin & carbapenem
Medications NOT to use in acute COPD exacerbation
-IV/PO theophylline
-chronic suppressive antibiotics
Gabby is a 17 year-old female recently diagnosed with asthma 2 months ago. At that time, she was started on Symbicort (budesonide/formoterol) 80/4.5mcg 2 puffs every 4-6 as needed for SOB. Today she follows up with her PCP and asthma is classified as partly controlled. Question: What is the best recommendation at this time?
A: Change Symbicort to Arnuity (fluticasone furoate) Ellipta 100 mcg 1 puff once daily and add albuterol as needed.
B: Continue Symbicort 80/4.5mcg but increase dose to 2 puffs twice daily and as needed.
C: Continue Symbicort 80/4.5mcg as needed and add Spiriva 1.25mcg 2 puffs once daily.
D: Change Symbicort to Dulera (mometasone/formoterol) 200/50 mcg 2 puffs twice daily and as needed.
A: Change Symbicort to Arnuity (fluticasone furoate) Ellipta 100 mcg 1 puff once daily and add albuterol as needed.
B: Continue Symbicort 80/4.5mcg but increase dose to 2 puffs twice daily and as needed.
Jason is a 19 y/o male college student who presents to your pharmacy for a refill on his rescue inhaler. Jason has a hx of asthma and has been well controlled on Advair 250/50 mcg 1 puff BID for about 10 months. He also has a prescription for Xopenex HFA at your pharmacy but it has not been filled in 9 months. He also has a hx of major depressive disorder and takes Sertraline 100mg QD. He reports rare daytime asthma symptoms (<1 time/month) and no nighttime symptoms over the last 5 or 6 months. He reports no rescue inhaler use over the last month and no limitation with regard to physical activity. Question: Six months have passed and Jason’s asthma control has worsened somewhat. His PCP wants to start montelukast 10mg one tablet every night at bedtime. Which is the best recommendation at this time?
A: Montelukast is not the best option for this patient due to a drug-drug interaction.
B: Montelukast is appropriate and may be started at this time.
C: Zafirlukast is the preferred leukotriene receptor antagonist due to evidence of increased efficacy.
D: Montelukast is appropriate, but the inhaled corticosteroid must be discontinue
E: Montelukast is not the best option for this patient due to his medical history
E: Montelukast is not the best option for this patient due to his medical history
Jason is a 19 y/o male college student who presents to your pharmacy for a refill on his rescue inhaler. Jason has a hx of asthma and has been well controlled on Advair 250/50 mcg 1 puff BID for about 10 months. He also has a prescription for Xopenex HFA at your pharmacy but it has not been filled in 9 months. He also has a hx of major depressive disorder and takes Sertraline 100mg QD. He reports rare daytime asthma symptoms (<1 time/month) and no nighttime symptoms over the last 5 or 6 months. He reports no rescue inhaler use over the last month and no limitation with regard to physical activity. Today, Jason is asking for an over-the-counter remedy to help alleviate his symptoms of sore mouth and throat. Upon inspection, you see white patches covering his mouth and throat and refer him to his primary care provider for suspected oral thrush. Which counseling point would reduce the likelihood of Jason developing oral thrush?
A: Use a holding chamber with Advair.
B: Use a holding chamber with Xopenex
C: Rinse mouth after using Advair.
D: Rinse mouth after using Xopenex.
E: Shake Xopenex prior to use.
C: Rinse mouth after using Advair.
Maria is a 35 year-old female with a history of asthma. She is currently managed on Advair Diskus (fluticasone propionate/salmeterol 100/50 mcg) 1 puff twice daily. Today, she follows up with her primary care provider and states that she her asthma has been “doing great” for the last 6 months. Upon questioning about her symptoms, her PCP determines her asthma is well-controlled. Question: What changes to Maria’s asthma regimen would you recommend today?
A: Change Advair to Symbicort (budesonide/formoterol) 80/4.5 mcg 2 puffs every 4-6 hours as needed and discontinue albuterol.
B: Change Advair to Dulera (mometasone/formoterol) 100/5 mcg 1 puff twice daily and as needed and discontinue albuterol.
C: Make no changes today.
D: Change Advair to Pulmicort (budesonide) Flexhaler 180mcg, 2 puffs twice daily and continue albuterol as needed.
A: Change Advair to Symbicort (budesonide/formoterol) 80/4.5 mcg 2 puffs every 4-6 hours as needed and discontinue albuterol.
Maria is a 35 year-old female with a history of asthma. She is currently managed on Advair Diskus (fluticasone propionate/salmeterol 100/50 mcg) 1 puff twice daily. Today, she follows up with her primary care provider and states that she her asthma has been “doing great” for the last 6 months. Upon questioning about her symptoms, her PCP determines her asthma is well-controlled. Question: How do you classify Maria’s asthma severity at this time?
A: Mild
B: Moderate
C: Severe
D: Severity cannot be assessed at this time
B: moderate
Richelle is a 45 year-old female who presents to her primary care clinic with complaints of sneezing, runny nose, and itchy/watery eyes. She reports some level of symptoms almost every day for at least 3 months out of the year. She has not had to miss work due to her symptoms, though now she is concerned that her symptoms will be mistaken for COVID-19 and she would like to treat them. Question: Which is the best recommendation?
A: Loratadine 10mg by mouth once daily
B: Olopatadine 0.1% solution, 1 drop in each eye twice daily
C: Azelastine 0.15% nasal spray, 2 sprays in each nostril twice daily
D: Loratadine + pseudoephedrine 5/120mg by mouth every 12 hours
A: Loratadine 10 mg by mouth once daily
Dominic is an 18-year old male with a diagnosed allergy to dogs. When exposed, his sypmtoms include rhinorrhea and itchy nose, and itchy/watery eyes. He presents to the pharmacy asking for a recommendation for a medication that he can use when he visits the homes of friends and family who have dogs. He does not report allergy symptoms otherwise and reports no medical history and no current medication use. Question: Which is the best recommendation?
A: Triamcinolone nasal spray, 2 sprays in each nostril 1 hour prior to exposure
B: Diphenhydramine 25mg by mouth every 4 hours as needed during exposure
C: Cromolyn nasal spray, 1 spray in each nostril 5-6 times per day as needed during exposure
D: Cetirizine 10mg, 1 tablet by mouth 1 hour prior to exposure
E: Ketotifen eye drops, 1 drop in each eye up to twice daily as needed during exposure
D: Cetirizine 10mg, 1 tablet by mouth 1 hour prior to exposure
AB is a 50 y/o female with chronic airway disease who reports a progressive hx of SOB present for ~ the last year. She smokes ~ 15 cigs per day and has smoked since she was 17 and notes that she had asthma as a child and used an inhaler until about the age of 12. She describes her airway symptoms as daily shortness of breath, particularly on exertion, but which also occasionally worsens overnight, causing her to wake with a cough. She also notes an allergy to dogs and cats which causes increased shortness of breath, wheezing, and chest tightness. Her primary care physician suspects asthma-COPD overlap (ACO). Question: Which is the BEST recommendation for initial controller therapy for AB?
A: Pulmicort Flexhaler (budesonide)
B: Spiriva Respimat (tiotropium)
C: Serevent Diskus (salmeterol)
D: Stioloto Respimat (tiotropium/olodaterol)
E: Combivent Respimat (albuterol/ipratropium)
A: Pulmicort Flexhaler (budesonide)
Joanne is an 87 year-old white female with COPD. She is rather frail and depends on her family to help administer her medication. Current COPD regimen includes: Anoro (umeclidinium/vilanterol) Ellipta 62.5/25mcg 1 puff daily Duoneb (albuterol/ipratropium) via nebulizer 4x/day as needed Joanne’s daughter tells you that she does not think her mother is getting her full dose of Anoro because powder falls out of the inhaler after she uses it. You ask the patient to show you how she uses the inhaler, and you notice she is not able to inhale with much force. Question: What is the best recommendation?
A: Start using a holding chamber with Anoro
B: Switch Anoro to Brovana (aformoterol) via nebulizer
C: Switch Anoro to Stiolto (tiotropium/olodaterol) Respimat
D: Use Duoneb as a scheduled med, rather than PRN
C: Switch Anoro to Stiolto (tiotropium/olodaterol) Respimat
James is a 65 year old Caucasian male with a past medical history (PMH) of COPD, afib, who presents to the emergency room complaining of increasing shortness of breath and fatigue. He tells you that his symptoms started about 4-5 days ago and came in because he was having difficulty walking because of his symptoms. He is also complaining of a runny nose, and a yellowish productive cough that has increased in amount from his baseline. PMH: COPD on 2 L O2 at home; Afib; DVT, Sleep Apnea, Obesity SH: Divorced; lives with his daughter; works as a mechanic a few days a week; has insurance through medicare; drinks alcohol on weekends (2-3 beers), smokes 2 cigarettes/day (down from 1ppd three years ago), denies illicit drug use Medications PTA: Apixaban 5mg po BID, Symbicort (Budesonide/Formoterol) 160mcg/4.5mcg 1 puff INH daily, Tiotropium (Respimat) 2 puffs INH daily, Diltiazem CD 360mg po daily, Bumetanide 1mg po daily Vitals: BP 158/92 HR 92 bpm RR 28/min O2 sat: 82% on 2 L PE: Gen: looks fatigue, having difficulty breathing CV: irregular rhythm Resp: Rhonci BL (L > R), decrease breath sounds likely due to body habitus Ext: no cyanosis, no edema The patient is going to be admitted to the inpatient medical floor. The medications you recommended previously are being started along with the following home medications: Apixaban 5mg po BID, Diltiazem CD 360mg po daily What other medications does the patient need? (SELECT ALL THAT APPLY)
A: Nicotine patch
B: Lovenox 40mg SQ daily
C: Singulair 10mg po daily
D: Magnesium 2gm IV
E: Influenza Vaccine
A: Nicotine patch
E: influenza vaccine
Q: Joe is 19 year-old male with asthma. He presents to your primary care clinic today for follow-up with his PCP. His current asthma regimen consists of Wixela (fluticasone propionate/salmeterol) Inhub 100/50 mcg 1 puff twice daily and albuterol 90 mcg 2 puffs every 4-6 hours as needed. Upon questioning, he reports that in the last 4 weeks, he has had daytime asthma symtpoms that require use of albuterol, on average, once per week. He notes 2 incidences of waking overnight with a cough and missed one day of work due to symptoms. Question: How would you classify Joe’s asthma control at this time?
partly controlled
Jackie is a 25 year-old black female who presents today for a visit with her primary care provider. Today, she complains of cough, chest tightness, and shortness of breath over the last several months. HPI: Patient presents for a physical as she will be starting a new job as a medical assistant. Approximately 6 months ago, she noticed shortness of breath while playing in the yard with her dog. Over the last month, she reports a cough on 3 or 4 occasions, sometimes accompanied by shortness of breath and chest tightness. She denies any nighttime waking with symptoms. Physical exam today: slight expiratory wheeze noted bilaterally, otherwise unremarkable Vitals: BP 112/72 mmHg HR 75 RR 18 O2 saturation 97% on room air SH: Denies cigarette smoking, alcohol use 2-3 drinks on the weekends, denies drug use, lives in apartment with boyfriend Current meds: cetirizine 10mg once daily for allergic rhinitis, oral contraceptive once daily Jackie’s PCP orders spirometry, but suspects asthma and requests your assistance in selecting an initial pharmacotherapeutic regimen. Question: What regimen would you recommend as initial asthma pharmacotherapy for Jackie? (Be specific, i.e. stop/start/continue, include drug/product name, strength (if multiple strengths avail), and dosing instructions.)
Start step 2 therapy with Symbicort (80/4.5 mcg/inh) Inhale 2 puffs every 4 to 6 hours as needed
Stacey is a 32 year old female with a history of moderate/severe persistent allergic rhinitis. Her primary care provider recommended initiation of fluticasone nasal spray, 1 spray in each nostril once daily. She has been using fluticasone daily for the last 3 weeks and contacts the office today reporting that symptoms have improved, but that she is still experiencing nasal congestion, particularly overnight and in the morning, as well as some residual rhinorrhea. Question: What changes to her regimen do you recommend today? (Be specific, i.e. stop/start/continue, include drug/product name, strength (if multiple strengths avail), and dosing instructions.)__1__
Add Azelastine 0.15% solution: 2 sprays in each nostril BID
Robbie is a 59 year old Black male. He presents to his primary care provider today for a post-discharge (transitions of care) follow-up visit. He was discharged 3 days ago after being admitted for a COPD exacerbation. Other than a short course of prednisone that was added, no changes were made to Robbie’s home meds upon discharge. In addition to COPD, Robbie has type 2 diabetes. Current medications: Prednisone 50mg once daily x 5 days Incruse (umeclidinium) Ellipta 62.5 mcg 1 puff daily Combivent (albuterol/ipratropium) Respimat 2 puffs 4x/day as needed for shortness of breath Metformin 1000mg twice daily Glipizide 10mg once daily Basaglar (insulin glargine) 40 units SQ once daily Discharge summary: No changes to home medications. Start prednisone 50mg once daily x 5 days. Blood eosinophil on admission day 1 = 30 cells/uL. mMRC today: 2 Question: What changes to Robbie’s COPD regimen would you recommend today? (Be specific, i.e. stop/start/continue, include drug/product name, strength (if multiple strengths avail), and dosing instructions.) __1__
Stop incruse and start Stilto Respimat 1 puff po bid|
Margaret is a 67 year old female who presents stating she is suffering from a “nagging” cough with phlegm. She has had this cough for over 4 months and states that over the past 2 years she has been having some “breathing troubles,” but she has not sought medical help until now. She explains that she feels “out of breath” after walking up a flight of stairs to her second floor apartment, a daily task that she has never had trouble doing prior to 2 years ago. Her primary care provider reviews her spirometry results and asks you for an inital therapy recommendation. PMH: type 2 diabetes, CAD (s/p NSTEMI in 2014), osteoporosis SH: cigarette smoker (0.5 ppdx 45 years), 1 glass of wine daily with dinner, denies recreational drugs Current meds: Metformin IR 500mg twice daily, atorvastatin 80mg daily, aspirin 81mg daily, calcium carbonate 600mg twice daily, alendronate 70mg once weekly Spirometry today: FEV1/FVC = 0.55 FEV1 = 43% predicted CAT score today: 18 Question: What non-pharmacologic intervention (list only one) would you recommend for COPD management in Margaret? __1__
smoking cessation
Margaret is a 67 year old female who presents stating she is suffering from a “nagging” cough with phlegm. She has had this cough for over 4 months and states that over the past 2 years she has been having some “breathing troubles,” but she has not sought medical help up until now. She explains that she feels “out of breath” after walking up a flight of stairs to her second floor apartment, a daily task thaht she has never had trouble doing prior to 2 years ago. Her primary care provider reviews her spirometry results and asks you for an inital therapy recommendation. PMH: type 2 diabetes, CAD (s/p NSTEMI in 2014), osteoporosis SH: cigarette smoker (0.5 ppdx 45 years), 1 glass of wine daily with dinner, denies recreational drugs Current meds: Metformin IR 500mg twice daily, atorvastatin 80mg daily, aspirin 81mg daily, calcium carbonate 600mg twice daily, alendronate 70mg once weekly Spirometry today: FEV1/FVC = 0.55 FEV1 = 43% predicted CAT score today: 18 Question: In addition to a rescue inhaler, what would you recommend for initial pharmacotherapy for COPD? (Be specific, i.e. stop/start/continue, include drug/product name, strength (if multiple strengths avail), and dosing instructions.) __1__
Start Spiriva respimat 2.5mcg 2 puffs daily
Fred is a 72 year-old Caucasian male. He is a retired pharmacist who also has a 50-year history of serving as a volunteer firefighter. Today Fred presents feeling “out of breath” and wheezing more. He states he is short-of-breath when walking from his front door to his mailbox at the end of his driveway. In addition to his breathlessness he has had a chronic cough without sputum production for the past 6 months. Fred is a former smoker, who quit 15 years ago (previously smoked 1ppd x 45 years). He reports occasional alcohol use and denies recreational drug use. Fred’s primary care provider diagnosed him with COPD and requests a clinical pharmacy consult. PMH: BPH, hyperlipidemia FH: Father deceased age 79 (history of COPD), mother deceased age 82 (history of HTN, hyperlipidemia) Current medications: Atorvastatin 10mg once daily, tamsulosin 0.4mg once daily, multivitamin once daily Spirometry today: FEV1/FVC = 0.67 FEV1 = 62% predicted CAT score today = 10 Question: How would you categorize the severity of Fred’s airflow limitation (GOLD grade AND severity) and COPD stage (ABCD)? (0.5 points each) GOLD Grade/Severity: __1__ Stage (ABCD): __2__
1: gold stage 2
2: B
Q: James is a 65 year old Caucasian male with a past medical history (PMH) of COPD, afib, who presents to the emergency room complaining of increasing shortness of breath and fatigue. He tells you his symptoms started about 4-5 days ago and came in because he was having difficulty walking because of his symptoms. He is also complaining of a runny nose, and a yellowish productive cough that has increased in amount from his baseline. PMH: COPD on 2 L O2 at home; Afib; DVT, Sleep Apnea, Obesity SH: Divorced; lives with his daughter; works as a mechanic a few days a week; has insurance through medicare; drinks alcohol on weekends (2-3 beers), smokes 2 cigarettes/day (down from 1ppd three years ago), denies illicit drug use Medications PTA: Apixaban 5mg po BID, Symbicort (Budesonide/Formoterol) 160mcg/4.5mcg1 puff INH daily, Tiotropium (Respimat) 2 puffs INH daily, Diltiazem CD 360mg po daily, Bumetanide 1mg po daily Vitals: BP 158/92 HR 92 bpm RR 28/min O2 sat: 82% on 2 L PE: Gen: looks fatigue, having difficulty breathing CV: irregular rhythm Resp: Rhonci BL (L > R), decrease breath sounds likely due to body habitus Ext: no cyanosis, no edema The patient is going to be admitted to the inpatient medical floor. For the following four medications: If you recommend, list the dose; if you do not recommend, list “NO”. Albuterol __1__ Prednisone __2__ Amoxicillin/clavulanic acid (Augmentin) __3__ Ciprofloxacin __4__
1: 2 puffs Q4h
2: 40 mg PO X 5 days
3: 875 mg PO BID x 5-7 days
4: NO
Larry is a 42 year old African American male who presents to the emergency department (ED) complaining of increasing shortness of breath (SOB) for the past 5 days. He has a past medical history (PMH) of asthma and tells you the SOB is worse with exertion and has not been improved by increasing his rescue inhaler. He states he has been using his rescue inhaler “multiple times” a day for the past 3-4 months- about 1.5 containers a month. He tells you he is not taking any of his other inhalers because he lost his job two months and hasn’t been able to afford them, but he tells you he rarely takes them normally because he doesn’t feel like they help. He also complains of fatigue, a runny nose, and just feeling generally “unwell.” He has no history of intubations or mechanical ventilation and his last visit to the ED for asthma was about 15 months ago. PMH: Asthma, kidney stones (3 years ago), knee pain, anxiety Social History: Divorced 3 months ago; lives alone; has 3 kids: one passed away, in contact with the other 2 children; worked as a barber until 2 months ago; recently lost his health insurance with job, denies alcohol use, denies smoking, occasional cocaine use (last use was 6 months ago). Medications PTA: Symbicort (Budesonide/Formoterol) 160mcg/ 4.5mcg 2 puffs INH BID, Singulair 10mg po daily, Albuterol 2 puffs INH q4h PRN, Ibuprofen 600mg po TID PRN prn WHILE IN THE ED and after treatment, the following information is provided: Vitals: BP: 168/98 HR: 128bpm RR: 32/min O2 sat-90% on RA Gen: looks unwell, sitting forward to breath, speaks in single words CV: RRR, no m/r/g Resp: BL wheezing throughout lung fields The patient has been admitted to inpatient medicine floor. For the following four medications: If you recommend, list the dose; if you do not recommend, list “NO”. 1-Albuterol, 2- Ipratropium, 3- Prednisone, 4- Singulair
1: 4-8 puffs Q 4 h
2: NO
3: 50 mg
4: NO
Larry is a 42 year old African American male who presents to the emergency department (ED) complaining of increasing shortness of breath (SOB) for the past 5 days. He has a past medical history (PMH) of asthma and tells you the SOB is worse with exertion and has not been improved by increasing his rescue inhaler. He states he has been using his rescue inhaler “multiple times” a day for the past 3-4 months- about 1.5 containers a month. He tells you he is not taking any of his other inhalers because he lost his job two months and hasn’t been able to afford them, but he tells you he rarely takes them normally because he doesn’t feel like they help. He also complains of fatigue, a runny nose, and just feeling generally “unwell.” He has no history of intubations or mechanical ventilation and his last visit to the ED for asthma was about 15 months ago. PMH: Asthma, kidney stones (3 years ago), knee pain, anxiety Social History: Divorced 3 months ago; lives alone; has 3 kids: one passed away, in contact with the other 2 children; worked as a barber until 2 months ago; recently lost his health insurance with job, denies alcohol use, denies smoking, occasional cocaine use (last use was 6 months ago). Medications PTA: Symbicort (Budesonide/Formoterol) 160mcg/4.5mcg 2 puffs INH BID, Albuterol 2 puffs INH q4h PRN, Ibuprofen 600mg po TID PRN pain List TWO risk factors that Larry has for an increase in asthma-related death? __1__ __2__
1: over use of SABA
2: poor adherence
