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ARCHIVED: Pharmacology for Nurse Anesthesia > Exam 4: Pulmonary Pharmacology > Flashcards

Exam 4: Pulmonary Pharmacology Flashcards

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1
Q

Pulmonary SNS innervation:

A

SNS fibers from thoracic ganglia innervating smooth muscles of bronchi, pulmonary blood vessels
Sympathetic tone: bronchodilation via β2 receptors

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2
Q

Pulmonary PSNS innervation:

A

Vagus nerve

Parasympathetic tone: bronchoconstriction via M3 receptors

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3
Q

β2 receptors in the lungs cause these effects (3):

A

Bronchodilation
Increased cAMP
Greater sensitivity to epi vs. norepi

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4
Q

NANC nerves & role:

A

Non-adrenergic, non-cholinergic; relax airway smooth muscle by releasing NO and VIP

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5
Q

M3 receptors in the lungs cause these effects (2):

A

Bronchoconstriction via IP3 –> ↑Ca2+

Increased mucus secretions

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6
Q

Effects of M3 stimulation on pulmonary blood vessels:

A

None

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7
Q

Asthma is:

A

Chronic inflammatory disorder of airways with increased responsiveness of tracheobronchial tree to stimuli

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8
Q

Characteristics of asthma obstruction:

A

Variable and reversible

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9
Q

Characteristics of airways during asthma:

A

Inflamed
Edematous
Hypersensitive to irritant stimuli

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10
Q

Cells activated in the bronchial mucosa by allergens:

A

Th2 lymphocytes (which release cytokines)

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11
Q

Mediator cells in asthma:

A

Eosinophils
Mast cells
Neutrophils
Macrophages
Basophils
T lymphocytes

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12
Q

Chemical mediators in asthma:

A

Cytokines
Histamines
Interleukins 3-4-5
Leukotrienes
Prostaglandins
Adenosine
Platelet activating factor

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13
Q

Atopic asthma:

A

Mediated by IgE

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14
Q

Goal of medications in asthma:

A

Flattening the response to mediators

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15
Q

Characteristics of COPD obstruction:

A

Non- or incompletely reversible

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16
Q

Causes (3) of cell damage in COPD:

A

Impaired lung parenchyma
Degraded matrix
Toxic action of macrophages and neutrophils

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17
Q

Changes to lung tissue in COPD:

A

Enlarged air spaces
Fibrosis
↑ mucus production

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18
Q

Steroid and bronchdilator efficacy in COPD:

A

Steroids: limited effect
Bronchodilators: modest role in breathlessness

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19
Q

Step 1 of airway outflow d/o treatment:

A

Short-acting bronchodilators

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20
Q

Step 2 of airway outflow d/o treatment:

A

Regular inhaled corticosteroid

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21
Q

Step 3 of airway outflow d/o treatment:

A

Long-acting bronchodilators

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22
Q

Step 4 of airway outflow d/o treatment:

A

Phosphodiesterase inhibitors
Methylxanthines
Leukotriene inhibitors

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23
Q

Step 5 of airway outflow d/o treatment:

A

Oral corticosteroid

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24
Q

Three classes of bronchodilators:

A

β-agonists
Anticholinergics
Methylxanthines

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25
Q

Short-acting β2-agonists:

A

Terbutaline
Albuterol
Levalbuterol
Salbutamol

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26
Q

Long-acting β2-agonist:

A

Salmeterol

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27
Q

Indication for long-acting β2-agonists:

A

Nocturnal asthma

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28
Q

Refresh: Stimulatory G-protein cascade?

A

Gαs → ↑cAMP → ↓Ca++

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29
Q

Onset of action of β-agonists:

A

Rapid; 15-30 min

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30
Q

Duration of action of β-agonists:

A

30-60 minutes

Salmeterol up to 4 hours

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31
Q

Indication for β-agonists:

A

Rescue inhaler

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32
Q

Delivery of β-agonists:

A

Inhalation/aerosol, powder or nebulized

Exception: terbutaline is SC

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33
Q

Side effects of β-agonists:

A

Tremor
↑ HR
Vasodilation
Hyperglycemia, hypokalemia (d/t insulin release), hypomag

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34
Q

Preferred β2-selective agonist:

A

Albuterol

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35
Q

Dosing of albuterol:

A

100 mcg/puff
2 puffs q4-6hr

2.5 - 5.0mg nebulized in 5ml saline

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36
Q

Duration of action of albuterol:

A

4 hours; some relief up to 8 hours

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37
Q

Anesthetic considerations for albuterol:

A

Additive effect with volatile anesthetics on bronchomotor tone

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38
Q

2 isomers of albuterol:

A

R-albuterol more β2 affinity

S-albuterol more β1 affinity

39
Q

Side effects of albuterol:

A

Tachycardia

Hypokalemia

40
Q

Anesthesia uses of albuterol:

A

4 puffs to blunt AW response to tracheal intubation in asthmatics

41
Q

Dosage of metaproterenol:

A

No more than 16 puffs/day

42
Q

Advantage of bitolterol:

A

Longer lasting

CV side effects rare

43
Q

Dosage of bitolterol:

A

16-20 puffs/day

270 mcg/puff

44
Q

Indications for terbutaline:

A

Asthma, esp. status asthmaticus

Preterm labor

45
Q

Delivery of terbutaline:

A

Oral, SC, inhalation

46
Q

Dosage of terbutaline:

A

SC: 0.25mg q15min (adult)
SC: 0.01 mg/kg (child)
MDI: 16-20 puffs/day
(200 mcg/puff)

47
Q

Examples of long-acting β-agonists:

A

Salmeterol
Advair: fluticasone and salmeterol
Formoterol

48
Q

Long-acting β-agonists are long acting because:

A

Lipophilic side chains resisting degradation

49
Q

Duration of action of long-acting β-agonists:

A

12-24 hours

50
Q

Indications for long-acting β-agonists:

A

Prevention, not flare-up

51
Q

Indications for anticholinergics:

A

Treatment of COPD

Secondary tx for asthma (resistant to β-agonist or w/ cardiac disease)

52
Q

Model of asthma exacerbation d/t viral infection:

A

Activated T-cell → eosinophilic activation → mediator release via degranulation → deposition on airway smooth muscle and stimulate PSNS bronchoconstriction

53
Q

Classification of atropine:

A

Naturally occuring tertiary amide alklaoid

54
Q

Dosing of atropine for asthma:

A

1-2mg neb in 3-5ml NS

55
Q

Side effects of atropine:

A

Tachycardia
Nausea
Dry mouth
GI upset

56
Q

Classification of ipratropium bromide:

A

Quaternary ammonium salt derived from atropine

57
Q

Dosing of ipratropium bromide:

A

40-80mcg in 2 puffs MDI or via neb

58
Q

Onset of ipratropium bromide:

A

Slow; 30-90 min

59
Q

Duration of action of ipratropium bromide:

A

4-6 hours

60
Q

Absorption of ipratropium bromide relative to atropine:

A

Not significantly absorbed, so less cardiac/systemic side effects

61
Q

Side effects of ipratropium bromide:

A

If inadvertently orally ingested, dry mouth/GI upset

62
Q

Structure of tiotropium:

A

Quaternary ammonium salt

63
Q

Duration of action of tiotropium:

A

Long acting

64
Q

Advantage of tiotropium:

A

Not significantly absorbed so few systemic side effects

65
Q

Indication for tiotropium:

A

COPD

66
Q

MoA for methylxanthines:

A

Nonspecific inhibition of phosphodiesterase isoenzymes

67
Q

Function of phosphodiesterase isoenzymes:

A

Prevent cAMP degradation → ↑cAMP → ↓Ca++ → bronchodilation

68
Q

Indications for methylxanthines:

A

COPD/asthma

69
Q

Examples of methylxanthines:

A

Theophylline

Aminophylline

70
Q

Therapeutic plasma level of theophylline:

A

10-20 mg/ml

71
Q

Toxic level of theophylline:

A

> 20 mg/ml

72
Q

Toxic level of theophylline:

A

> 20 mg/ml

73
Q

Drug interactions with theophylline:

A

Halothane (not in US)

Activates CYP450

74
Q

Side effects of methylxanthines:

A 
Arrythemias
N/V
Irritability
Insomnia
Seizures
Brain damage
Hyperglycemia
Hypokalemia
Hypotension
75
Q

Indication for inhaled corticosteroids:

A

Major preventative treatment for asthma

76
Q

MoA (3) of inhaled corticosteroids:

A

Alters genetic transcription to ↓ pro-inflammatory protein synthesis, ↑ anti-inflammatory proteins and β2 receptors
Induces apoptosis of inflammatory cells
Indirectly inhibits mast cells over time

77
Q

Relative importance of inhaled corticosteroids for asthma mgmt:

A

Most important drug in the arsenal!!

78
Q

Examples of inhaled corticosteroids:

A

Beclomethasone
Triamcinolone
Fluticasone
Budesonide

79
Q

Anesthesia uses of inhaled corticosteroids:

A

Consider using 1-2 hours pre-op

Consider 5 day course of combined inhaled corticosteroids/albuterol to minimize risk of intubation bronchospasm

80
Q

Drug interactions with inhaled corticosteroids:

A

Prolong the response of β-agonists (hence combination drugs like Advair)

81
Q

% of inhaled corticosteroids that reach the airway vs. the oropharynx:

A

25% into airway

80-90% into oropharynx

82
Q

Side effects of inhaled corticosteroids:

A 
Osteopenia/porosis
Delayed growth in children
Oropharyngeal thrush
Hoarseness
Hyperglycemia
83
Q

MoA of cromolyn:

A

Stabilizes mast cells and inhibits antigen-induced release of histamine
Inhibits the immediate allergic response to an antigen, BUT NOT the response once activated

84
Q

Indications for cromolyn:

A

Prevention, not rescue!

85
Q

Delivery of cromolyn:

A

Inhalation; 8-10% enters systemic circulation

86
Q

Dosing of cromolyn:

A

4 times daily

7 days to effect!

87
Q

Side effects of cromolyn:

A 
Infrequent but serious:
Laryngeal edema
Angioedema
Urticaria
Anaphylaxis
88
Q

Leukotrienes synthesized from:

A

Arachidonic acid in the presence of activated inflammatory cells

89
Q

MoA of zileuton:

A

Blocks the biosynthesis of leukotrienes

90
Q

Disadvantages of zileuton:

A

Low bioavailability
Low potency
Significant adverse effects
Hepatotoxic

91
Q

MoA of monteleukast:

A

Blocks the Cysteinyl-Leukotriene 1 receptors on the smooth muscle

92
Q

Drug interaction with monteleukast:

A

Coadministration with warfarin can prolong PT

93
Q

MoA of omalizumab:

A

Short-term: Binds to IgE antibodies and prevents their binding to mast cells to mitigate the acute response to inhaled allergen

Long-term: IgE receptors on mast cells/basophils/dendritic cells are down-regulated

94
Q

Delivery of omalizumab:

A

Given SQ for 2-4 weeks or parenterally infused; during early and late phase of asthmatic response

ARCHIVED: Pharmacology for Nurse Anesthesia (20 decks)

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