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