Lecture 10 (pulm)-Exam 5 Flashcards by Ashley Ruehle

Pathophysio

Asthma:
* Allergen from an environmental trigger picked up by what?
* What do the cells present them to?
* What is released after that?

Allergen from an environmental trigger picked up by dendritic cells
Dendritic cells present them to TH2 cells
TH2 cells release cytokines causing inflammation-> Cytokines (IL4 and IL5)

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Pathophysio

What does IL4 and IL5 cause?

IL4
* Stimulates B-cells to produce IgE which binds to Fc€RI receptors on mast cells
* Mast cells use phospholipase A2 to produce arachidonic acid (AA)
* AA metabolized by:
* COX to prostaglandins
* 5-LOX to leukotrienes

IL5
* Activates eosinophils
* Promotes immune response by releasing more cytokines and leukotrienes

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Asthma
* Airway obstruction caused by what? (irreversible or not?)
* Part of what triad?

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ASTHMA – GOALS OF TREATMENT
* Reduce impairment: Prevent what, require what, normal what?

Prevent chronic symptoms (if no txt: damage)
Require minimal use of reliever (ex: SABA)
Normal or near normal lung function and activity levels

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Asthma: goals of treatment:
* Reduce risk: Prevent what? (2) Minimize what? (2)

Prevent exacerbations
Minimize need for emergency care and hospitalization
Prevent decreased lung function
Minimize pharmacotherapy adverse effects

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What are the Nonpharmacologic treatment of asthma? (4)

Avoidance of environmental triggers
Avoidance of dietary triggers
Weight loss
Breathing exercise programs->Adults

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Medication definitions
* What is a reliever?
* What is a controller? Use with what?
* What is maintenance treatment?

Reliever
* For symptom relief or before exercise or allergen exposure

Controller (kinda like a mix of reliever and maintence)
* For symptom control and exacerbation risk
* Used with ICS-containing treatment

Maintenance treatment
* Used daily to prevent symptoms and exacerbations (e.g., twice a day)

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NIH treatment guidelines
* All asthma guidelines follow what?
* Specific steps of the ladder depend on what?

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Asthma classification
* Classification based on what?(2)
* What is each one based on?

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What is the classification of intermittent asthma? (Symptoms, nighttime awakings, SABA use, asthma excerbations for ages 0-4, 5-11, over 12)

This is step one

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What is the step one or intermittent astma txt?

SABA (reliever) as needed for symptoms
* All ages
* Use throughout all steps for symptom control in addition to other therapies

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What is new step one or intermittent asthma txt for 0-4 years old?

Consider short course ( 7 to 10 days) ICS at start of respiratory tract infection

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What are the two SABA choices?

Albuterol and levalbuterol

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Albuterol:
* What are the dosage forms?
* Usual dose rang for mild symptom control?
* Usual dose range for exacerbations?

Need to know the dosages for albuterol

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Levalbuterol:
* What are the dosage forms?
* What is the usual dose range for mild symptom control?
* What is the usual dose range for excerbations?

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What are the beta 2 adverse effects?

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What is the classifcation for Mild persistent asthma? (Symptoms, nighttime awakings, SABA use, asthma excerbations for ages 0-4, 5-11, over 12)

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Mild persistent or step 2:
* What is the preferred txt for all patients?
* What is the alternative txt for all patients?
* What do you with the controller? What does it not work as?

All Patients:
* Preferred treatment : low-dose ICS (controller)+ SABA for sx
* Alternative: montelukast

Controllers
* Take everyday regardless of symptomatic or not
* Will not work as rescue therapy

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For mild persistent asthma or step two:
* What should you consider for allergic asthma (adults+children over five)

Consider SC immunotherapy for patients with allergic asthma

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What are the different ICS? (you need to be able to recognize them)

Beclomethasone HFA (Qvar)
Budesonide DPI (Pulmicort)
Fluticasone propionate DPI (Flovent Diskus)
Fluticasone furoate DPI (Arnuity Ellipta)
Mometasone DPI (Asmanax Twisthaler)
Mometasone HFA (Asmanax HFA)

BE BUDs with FLUTtering MOM

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ICS:
* What are the different doses?
* When does the dose change?

Low – Med – High dose ICS
changes with age groups

Multiple strengths exist

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What is the classifcation for moderate persistent asthma? (Symptoms, nighttime awakings, and SABA use for ages 0-4, 5-11, over 12)

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Moderaten persistent asthma or step 3:
* What is the txt for patients 0-4 years old?

Preferred: medium dose ICS + saba for sx
Consult asthma specialist

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Moderaten persistent asthma or step 3: * What is the txt for patients over 5 years old? * What should you consider?

Preferred: * Medium dose ICS or * Low-dose ICS + LABA or LTRA (LTRA best for allergy or exercised indused asthma) * plus SABA for sx Consider SC immunotherapy for patients with allergic asthma

What are the different types of ICS/LABAs?

* Fluticasone-salmeterol * Budesonide-formoterol * Mometason-formoterol

What is the classifcation for severe persistent asthma? (Symptoms, nighttime awakings, and SABA use for ages 0-4, 5-11, over 12)

Severe Persistent asthma: * What is the treatment for patients of ages 0-4?

* Same as Step 3 therapy: **medium dose ICS** * Consult asthma specialist

Severe Persistent asthma: * What is the treatment for patients of ages 5-11?

Continue with Step 3 medium ICS option OR Step 4 * **Preferred**: medium dose ICS plus LABA * **Alternative**: medium dose ICS plus montelukast

Severe persistent asthma * What is the txt for 12+?

Step 4: * Preferred: medium-dose ICS + LABA * Alternative: medium-dose ICS + LTRA * Consult asthma specialist

What is the txt for step 5 Severe persistent asthma?

* High-dose ICS + LABA * Consider omalizumab for patients with allergies

What is the txt for step 6 severe asthma?

Same as step 5 with addition of oral corticosteroids

GLOBAL INITIATIVE FOR ASTHMA (GINA) GUIDELINES * What is this? * What is the evidence?

New evidence published in the last few years showing the benefit of ICS used with reliever agents * Strongest evidence with adults and adolescents ≥ 12 years * Some evidence and recommendations for 6 to 11 years * Minimal evidence for 5 and under

GINA guidelines: * What has been shown When compared to SABA alone, SABA + daily ICS, or daily ICS alone?

* Decrease severe exacerbations * Decrease systemic corticosteroid use * Decreased ED visits / hospitalizations

What is an anti-inflammatory reliever (AIR)

* E.g., ICS-formoterol, ICS-SABA * Provides symptom relief plus small dose of ICS

What is MART?

Maintenance And Reliever Therapy with ICS-formoterol = MART * ICS-formoterol used as maintenance therapy AND PRN symptom relief * One inhaler

Global initiative for Asthma (GINA) Guidelines * What age group is it for? * What is Step one and two?

Adults and adolescents ≥ 12 years Steps 1 and 2 * As needed low dose ICS-formoterol

What is step 3 of gina?

Low-dose maintenance ICS-formoterol plus PRN ICS-formoterol

What is step 4 of gina?

Same as step 3 but medium dose ICS-formoterol

What is step 5 of gina?

Same as step 4 (medium dose ICS-formoterol) but add LAMA

Give an example of the GINA stepwise

FOLLOW-UP ASSESSMENTS * When do you re-evaluate? * Control based on what? (What does the pt recall and what measurements?)

Re-evaluate every 2 to 6 weeks until well-controlled then every 3 to 6 months Control based on most severe impairment * Patient / caregiver recall of events over last 2 to 4 weeks * Spirometry / peak flow measurements

Follow up assessment: * Explain the use of stepwise approach?

Step **down** if symptoms controlled for at least 3 months Step **up** if needed * Check compliance, inhaler technique, environmental control and comorbidities first (before switching) * If alternative therapy was used; switch to preferred therapy for current step before increasing a step

EXERCISE-INDUCED ASTHMA * What does it describe? * Exercise-induced bronchoconstriction occurs in how many people? * Can be an indicator of what?

* Exercise-induced bronchoconstriction (EIB) describes a transient airway narrowing occurring during physical exertion * Exercise-induced bronchoconstriction occurs in 40% to 90% of people with asthma and up to 20% of the general population without asthma * Can be an indicator of poorly controlled asthma

Exercise induced asthma: * What is the txt?

ASPIRIN SENSITIVE ASTHMA * Blocking the COX pathway increases what? * What is the pathway/ what does this cause? * What is there a cross reactivity between?

* Blocking the COX pathway increases the production of lipoxygenase * Increases the production of leukotrienes * Induces bronchospasm * Cross reactivity between NSAIDS exists

PEAK FLOW METERS * What does it measure? (2) * What can it help determine?

* Measures how fast a patient can push air out of lungs when blowing out as hard as they can * Helps measure how open the airways are * Helps determine when adjustments to home regimen are necessary

Peak Flow Meter * May start to decrease when? * Part of what? * Zones can be set up initally based on what? * Individualized zones can also be set up if what?

* May start to decrease before other identifiable symptoms * Part of asthma action plan * Zones can be set up initially based on height and sex * Individualized zones can also be set up if patient healthy

What is an asthma action plan?

ASTHMA EXACERBATIONS * What is it? * Management may occur where? Depends on what?

Worsening of asthma symptoms requiring temporary increase in treatments Management may occur at home or in the hospital * Depends on severity of exacerbation and underlying disease

Asthma exacerbations: * What are the sxs of more severe exacerbation?

* No breath sounds (no air mvt) * Taking in single words or no talking * Tachycardia / bradycardia * Perioral cyanosis * Hypoxemia * Hypotension * Patients at high-risk of poor outcomes->hospitalization * Most institutions – treatment protocolized

What are the factors that increase asthma related death?

MILD – MODERATE EXACERBATIONS * What is the txt?

# asthma What are the sxs of mild-moderate exacterbations?

# asthma SEVERE EXACERBATION * What are the first line initial therapies?

# asthma What are the sxs of servere exacerbation

# asthma What are some other therapies for severe exacterbations?

What is the MOA of COPD and what are the subtypes?

COPD: * What does structural lung changes lead to? (3)

* Increased resistance to airflow * Air trapping * Hyperinflation

Fill in for COPD

COPD GOLD GROUPS * What is treatment based on?

Treatment decisions based on prior year history of: * Symptoms – mMRC, CAT scores * Risk (exacerbations)

Fill in for GOLD

What is MRC dyspnea score and list the levels

What is the CAT score and what is the maximum score possible?

What are the treatment goals of COPD?

What is the pathophysio of Chronic bronchitis and emphysema?

COPD treatment * What are the non-pharmacologic therapy?

COPD txt: * What are the different vaccines that need? (give subtypes, and when they need them)

Smoking cessation: * How can you give behavioral support?

* Ask-identify users * Advise - cessation * Assess - willingness * Assist - support * Arrange - follow-up

smoking cessation: * What is the first line pharm?

depends on patient preferences, cost, etc * Nicotine (at least two products) * Varenicline (Chantix) * Bupropion (Zyban)

What is the MOA, SE, dosage form and comments of Varenicline?

What is the MOA, SE, dosage form and comments of Bupropion?

What is the MOA, SE, dosage form and comments of Nicotine?

What are all the different nicotine products?

Patch, gum, lozenge, inhaler, nasal spray

Nicotine patch: * What is the dosing and how do you administer?

Need to use patch then use gum or lozenge as needed

COPD: Group A * What are the txt? * What are the effects?

SAMA or SABA * Prevent or reduce symptoms * Improve FEV1 * Combination SAMA/SABA superior to either agent alone LAMA or LABA * Improve FEV1, dyspnea, health status, reduced exacerbations * LAMAs – greater reduction in exacerbations and hospitalizations compared to LABAs * Combination LAMA/LABA superior to either agent alone ## Footnote SABA/SAMA or both for rescue therapy for all groups!

COPD: Group A * What is preferred for all patients expect those with what?

Long-acting bronchodilator preferred for all patients except those with only occasional breathlessness * LAMA or LABA

COPD: Group A * What do you give patients with only occasinoal breathlessness? * What does that cause?

SABA or SAMA or SABA+SAMA as needed * Increase airway diameter * Decrease air trapping * Improve air flow * Decrease dyspnea

Group B COPD: * What is the txt?

LABA + LAMA

Group B COPD with LABA+LAMA: * When can agent can be tried alone? * No literature supporting what? * atient on monotherapy with a LABA or LAMA with persistent dyspnea should be escalated to what?

Group E COPD: * What is the txt?

* LABA + LAMA * LABA + LAMA + ICS if blood eosinophils ≥ 300

# A WORD ABOUT ICS FOR COPD * What does regular use of ICS increase the risk of? * What does the studies show? * Patients with asthma should have what?

* Regular use of ICS increases the risk of pneumonia * If ICS are utilized – studies show **LAMA + LABA + ICS** therapy superior to dual therapy with LAMA + ICS or LABA + ICS * Patients with asthma should have ICS incorporated into their treatment regimen

What is the criteria what strongly favors use ICS, Favors use and against use?

Fill in for COPD

Follow up pharmacologic treatment-> What happens if it does not work: * What do you check? * What do you consider? * Treat according to what? * Follow which chart if both set of traits are present?

What is the flow chart if patient is have dypnea at the follow up pharm appointment?

What is the flow chart if patient is have Exacerabation at the follow up pharm appointment?

ROFLUMILAST * What is the MOA? * What does it decrease? * What is the route?

ROFLUMILAST * What are the SE?

When is AZITHROMYCIN recommended?

Recommended for patients with COPD and ≥ 2 exacerbations / year despite optimal medical treatment (cannot be current smokers

Azithromycin for COPD * What types of effects? * Increases what? * Waht does it reduce? * What does it improve? * **What are the SE?** * What is the dose?

# A WORD ABOUT INHALERS * When do you do education?

Education and training critical * Prior to initial use * At each appointment

# A WORD ABOUT INHALERS Inhaler type dependent on what? (3)

* Patient preference/ability (cognition, dexterity, strength, inhalation strength) * Provider preference – should only prescribe inhalers they know how to use * Cost

# A WORD ABOUT INHALERS * What should be limited? * What should be verifed before deeming regimen ineffective?

* Inhaler types per patient should be limited (ex: ALL MIST) * Inhaler technique and adherence should be verified before deeming regimen ineffective

What are the difficulties that elderly patients face?

LONG-TERM OXYGEN THERAPY (> 15 HOURS PER DAY) * Increase survival in who? * Most improvement after what? * What does it improve?

What is the criteria for oxygen therapy in COPDers?

Fill in for O2 and COPDers

She said this is FYI but Idk about that lol

# COPD EXACERBATION * What is COPD natural history? * What is COPD exacerbation?

* COPD natural history – recurrent exacerbations associated with increased symptoms and decline in health status * COPD exacerbation - acute increase in symptoms beyond normal day-to-day variation

What are the sx of COPD exacerbation?

COPD EXACERBATIONS * What are causes (3)

COPD EXACERBATIONS * What is the duration? * What happens if not fully recovered in 8 weeks? * Hospitalized for what?

COPD EXACERBATION CLASSIFICATION * What is Mild?

COPD EXACERBATION CLASSIFICATION * What is moderate?

COPD EXACERBATION CLASSIFICATION * What is sereve?

COPD EXACERBATION TREATMENT * What is the short term txt?

* Reduce symptoms * Prevent hospitalizations * Shorten hospital stay * Prevent acute respiratory failure or death

COPD EXACERBATION TREATMENT * What is the long term txt?

* Minimize negative impact of exacerbations * Prevent future exacerbations * Strongest predictor is past exacerbations

What does CMS do/

CMS – incentives to reduce COPD readmissions

The majority of patients treated as outpatients * What is the General hospitalization criteria

Fill in for COPD exacerbation txt

Fill for COPD exacerbation txt

# COPD CORTICOSTEROID THERAPY * What are the benefits?

# copd CORTICOSTEROID THERAPY * What are the risks

# copd What is the dose of CORTICOSTEROID THERAPY?

Prednisone 40mg/day or equivalent x 5 days

ANTIBIOTIC THERAPY * What does it decrease (3)? * What is the duration?

* Decreases short term mortality (77%) * Decreases treatment failure (53%) * Decreases sputum purulence * Recommended duration: 5 to 7 days

Antibiotic: * Who gets it? * What pathogens? * What is the recommended therapy?

IDIOPATHIC PULMONARY FIBROSIS (IPF) * What is it? * What is the pathophysio? * What is early disease sx? * Managed how?

IPF - TREATMENT * What is the supportive care txt?

What are the medical txt for IPF?

IPF – ANTIFIBROTIC MEDICATIONS * What do they do?

Nintedanib * What is the MOA? * What are the SE? * What do you need to monitor?

Pirfenidone * What is the MOA? * What are the SE?

SARCOIDOSIS * What is it? * Can affect what? * Predominant in who? * What are the complications of advance disease? (3)

Sarcoidosis: * What are the symptoms?

What are the dx tests for sarcoidosis?

SARCOIDOSIS STAGING * What are each of the stages? What do they look like on x-ray?

Mild disease of sarcoidosis: * Who is in this group? * Reevluate when? * Resolve whan? * May consider trial of what? But txt is normally what?

Sarcoidosis: Symptomatic disease with more severe lung involvement * Txt for what? * How else may also benefit from txt?

* Treatment indicated to reduce granulomatous inflammation and reduce permanent lung damage * Patients with multi-organ involvement may also benefit from treatment

SARCOIDOSIS - TREATMENT * What is first line? * What should you consider for supplments?

What is second line for sarcoidosis?

* Methotrexate * Azathioprine

PNEUMOCONIOSIS * What is this?

ACUTE SILICOSIS * What does it show on CT?

SIMPLE SILICOSIS * What does it show on x-ray?

eggshell on x-ray

SILICOSIS - TREATMENT * What do you need to stop? * Withdrawal from what? * Supplemental what? * What can be given (meds) * What is prevention? * Manage what? * WHAT IS NOT RECOMMENDED? * What is the cure?

ASBESTOSIS - TREATMENT * What do you need to stop? * Withdrawal from what? * Supplemental what? * What needs to be treated? * What is prevention? * Manage what? * Monitor for what?

BERYLLIOSIS - TREATMENT * What is the txt?