Lecture 4: Acute Asthma and COPD

Question 1

Asthma Exacerbation
What is an asthma exacerbation?

Answer 1

– Represents a change from the patient’s usual status
that requires a change in treatment
– Progressively worsening asthma symptoms: Shortness of breath, cough, wheezing, and chest tightness (Can be combination of symptoms)
– Decreases in expiratory airflow –> Quantified by measurements of lung function (Peak expiratory flow (PEF) and Forced expiratory volume in 1 second (FEV1))
– Poorly responsive to usual bronchodilator therapy

Question 2

Asthma Exacerbation – Triggers

Answer 2

1.) Medications
– ASA, NSAIDS, beta-blockers
2.) Environmental
– Cold air, tobacco and wood smoke
3.) Respiratory infections (viral)
4.) Allergens
– Pollens, dust mites, animal dander, fungal spores, cockroaches

Question 3

Risk Factors for Death From Asthma

Answer 3

• Previous severe exacerbation (intubation, mechanical
  ventilation)
• Hospitalization or emergency care visit for asthma in the past year
• Current or recent use of oral corticosteroids (OCS)
• Use of > 1 canisters of inhaled short-acting β2-agonist
  (SABA) per month
• History of psychiatric disease
• Poor adherence with asthma medications and/or written asthma action plan
• Not currently using inhaled corticosteroids
• Food allergy in patient with asthma

Question 4

Management: Home Treatment

Answer 4

Pharmacologic therapy
– Increase frequency of SABA treatment
– Initiate oral systemic corticosteroid burst (1-2 mg/kg/day (max 50-60 mg/day); 3-10 days)
– Continue more intensive treatment for several
days

Question 5

Management: Home Treatment -Not recommended

Answer 5

– Drinking large volumes of liquid
– Breathing warm, moist air
– Using OTC products: Antihistamines, Cough and cold products
– Pursed-lip and controlled breathing… May help maintain calm but does not improve lung function
.
* No studies demonstrate effectiveness and
may delay getting appropriate care

Question 6

Home Management Case
Tony is a 35 yo male with a diagnosis of moderate persistent asthma who calls the clinic where you work. Tony tells you that he is calling from home. He states that he is currently experiencing increased coughing. Per the NHLBI guidelines, which of the following regimens is most appropriate to initially treat Tony’s asthma exacerbation?
A. Albuterol MDI 6 puffs X 2
B. Albuterol MDI 6 puffs X 2, ipratropium MDI 6 puffs
C. Albuterol MDI 6 puffs X 2, prednisone 60 mg po
D. Albuterol MDI 6 puffs X 2, ipratropium MDI 6 puffs, prednisone 60 mg po
E. Albuterol nebulization 5 mg, ipratropium nebulization 0.5 mg, prednisone 60 mg IV

Answer 6

A!

For initial treatment it should just be albuterol. Most patient’s do not have ipratropium at home (for COPD maybe…but not for asthma). Prednisone is also not an initial treatment.

Question 7

Home Management Case
After taking the initial treatment that you recommended,
Tony tells you that he is still experiencing persistent
dyspnea. He also mentions that he measured his peak
flow, and the reading is now 350 L/min. Tony tells you his
peak flow is usually 550 L/min.

Based on the NHLBI guidelines, provide a plan for Tony for the treatment of his exacerbation.

Answer 7

Continue albuterol but also give him SABA and prednisone (oral steroid)!

Question 8

Management: Emergency Department (this will be provided for you on the exam but just be familiar with it)

Answer 8

Question 9

Management: Emergency Department: 1st step: Inhaled SABA for all patients

Answer 9

Inhaled SABA for all patients!
– MDI or nebulizer, every 20 minutes or continuously
.
Albuterol
1.) MDI (90 mcg/puff)
- 4-8 puffs every 20 minutes X 1 hour, then every 1- 4 hours as needed
- Same efficacy as nebulizer if done correctly, use
with valved holding chamber
2.) Nebulizer
- 2.5-5 mg every 20 minutes for 3 doses, then 2.5- 10 mg every 1-4 hours as needed
- 10-15 mg/hr continuously
– Use higher dose for severe exacerbation

Question 10

SABA Dosing Considerations

Answer 10

• Dry powder inhalers not recommended
• Dose-response curve shifted to right, decreased
  duration of effect (Higher and more frequent doses needed during acute exacerbation)
  .
  AEs
  – Tachycardia, hyperglycemia, hypokalemia, tremors,
  restlessness, anxiety
  – Tachycardia also seen with asthma exacerbation and
  may resolve with appropriate disease treatment

Question 11

Management: Emergency Department: Oral corticosteroids

Answer 11

Oral corticosteroids
– Oral as effective as intravenous (use IV if patient can’t tolerate po meds)
- Emergency department/hospitalization (40-80 mg/day (peds: max 60 mg)) for typically 5-7 days
.
AEs
– Insomnia, glucose intolerance, mood alteration, increased appetite, GI distress

Question 12

Management: Emergency Department: Ipratropium and dosing consideration

Answer 12

• Not first line therapy or sole bronchodilator
• Can mix solution for nebulization with albuterol
• In moderate to severe exacerbations
  – Associated with fewer hospitalizations and greater
  improvement in lung function compared with SABA
  alone
• Questionable benefit once the patient is hospitalized
  .
  Ipratropium Dosing Considerations
  1.) MDI (17 mcg/puff)
  – 8 puffs every 20 minutes as needed up to 3 hours
  2.) Nebulizer
  – 0.5 mg every 20 minutes for 3 doses, then every 2-4 hours as needed
  .
  AEs
  – Systemic effects are rare, contact with eye
  produces pupillary dilation and decreased
  accommodation

Question 13

Management: Emergency Department… Other treatments/ what is not reccomeneded?

Answer 13

1.) IV magnesium sulfate
- Not initial therapy
- Can reduce hospitalizations
….Adults with FEV1 < 25-30% of predicted
….Adults and kids that fail to respond to initial therapy
….Kids whose FEV1 < 60% after 1 hour of treatment (2 g infusion over 20 minutes)
.
Not recommended
– Methylxanthines
– Antibiotics (unless infection present)
– Aggressive hydration
– Mucolytics
– Sedation
– Chest physical therapy

Question 14

Monitoring: ED and Hospital

Answer 14

Question 15

Hospital Management Case
CC: I can’t breathe
HPI: 48-year-old female arrives at the ED with URI symptoms x 4 days; has progressively worsening dyspnea and perioral cyanosis.
PMH: Asthma; no previous intubations, 3 ED visits in the past 9 months with last ED visit 3 months ago, last oral steroid burst was 3 months ago, GERD, depression, S/P Broken right forearm 2 years ago, S/P renal stones 9 years ago
Meds
Albuterol MDI 2 puffs PRN
Advair® Diskus® 250/50, 1 inhalation BID
Lansoprazole 30 mg po BID
Lexapro 20 mg once daily
.
All: NKDA
SH: Divorced with three children; lives in an apartment. Works as a dental hygienist. Denies current use or h/o tobacco, EtOH, IVDA, or crack/cocaine.
ROS: (+) chest tightness, labored breathing, and wheezing
PE: VS: BP 155/92, P 112, T 37.8 C, R 24, O2 sat: 88%, Wt 68 kg, Ht 5′6″
Gen: Alert but taking several breaths between words
Respiratory: (+) accessory muscle use, decreased breath sounds bilaterally with high-pitched, expiratory wheezes
Labs
PEF: 160 L/min; personal best 400 L/min
CXR: No acute processes, no masses
One year ago: PFTs: FEV1 2.94 (85%), FEV1/FVC 0.90
.
1. What is the most likely precipitant for this exacerbation?

2. Does this patient have any risk factors for dying from an asthma exacerbation?
3. Based on the presented guidelines, recommend the most appropriate initial treatment for this patient. Include medication(s), medication strength(s), dose(s), route(s) of administration, and dosing interval(s) of any medications you would like the patient to receive.

Answer 15

1. What is the most likely precipitant for this exacerbation? Upper respiratory infectious
2. Does this patient have any risk factors for dying from an asthma exacerbation?
   Yes
3. Based on the presented guidelines, recommend the most appropriate initial treatment for this patient. Include medication(s), medication strength(s), dose(s), route(s) of administration, and dosing interval(s) of any medications you would like the patient to receive.??
   What do we have to look at first is 02, heart rate, RR! we need to see if she is having a mild, mod or severe exacerbation. Patient is experiencing severe (look at PEF and O2) so the tx is:
   -High dose albuterol - 8 puffs or 5mg neb Q 20min x3
   -Ipratropium - 8 puffs or 0.5mg neb Q 20min x
   and - oral prednisone 60mg (40-80mg) QD until PEF > 70%

Question 16

Discharge… Prior to discharge __________

Answer 16

1.) Prior to discharge adjust medications to outpatient regimen
2.) Discharge medications
– SABA
– Complete course of oral corticosteroids
– Long-term control therapy
3.) Consider inhaled corticosteroids therapy
4.) Patient Education

Question 17

Now jumping into COPD

Answer 17

yay

Question 18

COPD Exacerbations and classification

Answer 18

• Characterized by increased dyspnea and/or cough and sputum that worsens in < 14 days
• Most common cause is respiratory tract infection (Usually viral)
• Goal of treatment: Minimize negative impact of current exacerbation and Prevent subsequent events
  .
  Classification
  1.) Mild
  – Treated with short-acting bronchodilators only
  2.) Moderate
  – Treated with short-acting bronchodilators + oral steroids +/- antibiotics
  3.) Severe
  – Patient requires hospitalization or ED visit
  – May be associated with acute respiratory distress

Question 19

COPD Exacerbation Assessment

Answer 19

Question 20

COPD: Indications for Hospital Admission

Answer 20

1.) Severe symptoms
– e.g. sudden worsening of resting dyspnea, high
respiratory rate, decreased oxygen saturation, confusion, drowsiness
2.) Acute respiratory failure
3.) Onset of new physical findings
– e.g. cyanosis or peripheral edema
4.) Failure to respond to initial medical management
5.) Presence of serious comorbidities
– e.g. heart failure, newly occurring arrhythmia
6.) Insufficient home support

Question 21

COPD: Indications for ICU Admission

Answer 21

1.) Severe dyspnea that responds inadequately to initial emergency therapy
2.) Changes in mental status
– Confusion, lethargy, coma
3.) Persistent or worsening hypoxemia and/or respiratory acidosis despite O2 and noninvasive ventilation
4.) Need for invasive mechanical ventilation
5.) Need for vasopressors

Question 22

COPD: Acute Exacerbation – Outpatient Management

Answer 22

1.) Bronchodilators (SABA ± SAMA)
– Symptom improvement not affected by route of
delivery
2.) Corticosteroids
– Prednisone 40 mg PO once daily x 5 days
3.) Antibiotics if indicated
– Common pathogens: Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis
– Duration: 5-7 days
4.) May escalate home oxygen (goal O2 Sat 88-92%)
5.) Diuretics if fluid overload due to comorbidities

Question 23

COPD: Acute Exacerbation – Inpatient Management

Answer 23

1.) Supplemental oxygen (goal: 88-92%)
2.) Bronchodilators
– Increase doses and/or frequency
– SABA + SAMA
3.) Oral corticosteroids
4.) Antibiotics if indicated
5.) Noninvasive mechanical ventilation if needed
6.) Monitor fluid balance
7.) Consider thromboembolism prophylaxis
8.) Identify and treat associated conditions
– Heart failure, arrhythmias, pulmonary embolism etc
9.) If admitted to ICU
– Invasive mechanical ventilation
– Vasopressors

Question 24

COPD: Indications for Antibiotic Therapy

Answer 24

1.) Patients with increased dyspnea, sputum
volume, and sputum purulence
2.) Patients with increased sputum purulence
AND increased dyspnea
3.) Patients with increased sputum purulence
AND increased sputum volume
4.) Patients requiring mechanical ventilation

Question 25

COPD: Discharge

Answer 25

1.) Check maintenance therapy and understanding
2.) Reassess inhaler technique
3.) Ensure understanding of withdrawal of
acute medications (steroids and/or antibiotics)
4.) Assess need for continuing oxygen
5.) Provide management of comorbidities
6.) Follow-up in ~ 4 weeks

Question 26

COPD Case
Dwayne is a 66 yo male who calls the Family Medicine
Clinic where you are the clinical pharmacist. Dwayne has
been diagnosed with COPD and is currently receiving
treatment with Stiolto® Respimat ® and prn albuterol.
Dwayne states that he is having an increase in his
symptoms. He is having shortness of breath – even when
he’s just sitting down watching television which has never happened before. His wife says that she has noticed blueness around his mouth. Upon further questioning Dwayne admits to coughing up increased sputum and that the sputum is purulent.
.
1. Does Dwayne have any indications for a hospital admission? For an ICU admission?
.
2. Recommend the most appropriate therapeutic regimen for Dwayne at this time.

Answer 26

1. Does Dwayne have any indications for a hospital admission? For an ICU admission? Hospital admission: Shortness of breath when resting, cyanosis and severe symp! ICU admission? not yet!
   .
2. Recommend the most appropriate therapeutic regimen for Dwayne at this time.
   albuterol, ipratropium (SABA and SAMA) , prednisone, abx (he’s qualified b/c he has increased SOB, sputum purulent, and increased sputum. We need to watch his O2 as well and monitor fluid balance and consider thromboembo prop.