Module 5: Respiratory (a) Flashcards
Asthma
-Definition
- Chronic inflammatory dz of the airway
2. External stimuli cause inflammatory cells to release mediators (ex: histamine, Leukotriene’s) causing asthma symptoms
Goal of Asthma Therapy
-2 domains?
- Reducing impairment
- Prevent chronic symptoms
- Infrequent use of SABA
- Maintain near normal PF
- Maintain normal activities
- Meet patients’/families’ satisfaction w/ care - Reducing Risk
- Prevent exacerbations, ED visits and hospitalizations
- Prevent loss of lung function/growth
- Optimal treatment w/ little to no adverse events
Goal of Asthma Therapy
-Domain 1 (Reducing Impairment)
- Reducing impairment
- Prevent chronic symptoms
- Infrequent use of SABA
- Maintain near normal PF
- Maintain normal activities
- Meet patients’/families’ satisfaction w/ care
Goal of Asthma Therapy
-Domain 2 (Reducing Risk)
- Reducing Risk
- Prevent exacerbations, ED visits and hospitalizations
- Prevent loss of lung function/growth
- Optimal treatment w/ little to no adverse events
Asthma
-Quick Relief Therapy
- Bronchodilators
- SABA’s
- Anticholinergics - Systemic Corticosteroids
- Inhaled Corticosteroids + formoterol (LABA)
Asthma
-New 2020 recommendations
- SABA’s are recommended in conjunction w/ ICS for management of asthma-related symptoms
- Less effective than inhaled beta agonists—slower onset of action and aches less Bronchodilation
SABA
-Indication
- Acute PRN treatment of Bronchospasm
2. Treatment at the start of respiratory tract infection w/ ICS**
SABA’s
-MOA
- Activates adenlyate cyclase and increases cAMP thereby relaxing smooth muscle and relieving broncho-constriction.
- Onset = 5 minutes
SABA’s
-Contraindication and S/E
- Ischemic heart dz
- HTN, arrhythmia
- Seizures and hyperthyroidism
Caution with:
- Tricyclics, MAO inhibitors
- Antagonized by beta blockers
- SABA’s and beta blockers can block each other
SABA’s
-A/E
- Tachycardia & palpitations
- Tremor
- Hypokalemia
- Hyperglycemia
- Headache and dizziness
SABA
-Albuterol Inhaler availability/dosing?
- MDI ProAir, Ventolin, Proventil 90mcg/spray (All brand name; expensive)
Admin:
-2 puffs every 4-6hrs PRN wheezing - For Exercise induced Asthma:
- 2 puffs inhaled 5-30 minutes before exercise
SABA
-Albuterol Nebulizer dosages and admin?
- 2.5mg/3ml (0.083%)
- 5mg/ml (0.5%)
Bronchospasm
-2.5mg per neb q6-8hrs PRN Max dose 10mg/day (4 total doses daily)**
Acute Bronchospasm**
-2.5-5mg per neb q20 min x3 AND CALL 911
SABA
-Levalbuterol (Xopenex) Dosing per age
- > 4 yrs = MDI 45mcg/spray 2 puffs q4-6 hrs PRN
- 6-11 yrs =0.31mg - 0.63 mg NEB TID PRN
- > 12 yrs = 0.63 - 1.25 mg NEB TID PRN
Antimuscarinics/Anticholinergics
- Info
- Short and Long acting
- Used MOST frequently in COPD
- Ipratropium-Albuterol (Combivent)
- Second-line quick relief medication for asthma
Not supported by GINA
Long Term Asthma Control
-Examples
- Inhaled Corticosteroids (GOLD STANDARD)**
- Leukotriene modifiers
- Cromolyn
- Methylxanthines
- LABA’s
- Immunomodulators
Inhaled Corticosteroids
-Info?
- Used to reduce symptoms, reduce exacerbations, and reduce use of SABA, while improving PF
- Used for Mild and Persistent asthma
- Intermittent asthma for quick relief therapy
- Add-on + SABA at the start of a worsening or a respiratory tract infection**
Inhaled Corticosteroids
-MOA & Onset
- Reduce eosinophils and mast cells in airways
- Reduce airway hyperresponsiveness by reducing inflammation
- Reduce responsiveness to histamine, exercise, allergens or irritants
- Onset = 2 weeks of continuous therapy for max effectiveness
Inhaled Corticosteroids
-Caution w/ Children
- Can stunt growth with children
- Use lowest dose w/ a spacer with children under 5 yrs old. - Less risk than oral corticosteroids
- Pregnancy/lactating risk of fetal adrenal suppression
Inhaled Corticosteroids
-A/E
- Oropharyngeal Candidiasis (THRUSH)
- RINSE mouth after use**
Inhaled Corticosteroids
-Use in pregnancy?
- Use Pulmicort as drug of choice during pregnancy
Inhaled Corticosteroids
-Medication examples?
- Beclomethasone (Qvar)
- Budesonide (Pulmicort)
- Ciclesonide (Alvesco)
- Fluticasone (Flovent)
- Mometasone (Asmanex)
Leukotriene Modifiers
-Info
- Alt treatment option for mild persistent asthma
- Adjunct w/ ICS 12 years and older - MOA
- Blocks binding of leukotrienes to receptors recurring contraction of smooth muscle, vascular permeability, mucus secretions and activation of inflammatory cells
Leukotriene Modifiers
-Contraindications/Caution & A/E’s
- Contraindicated for reversal of ACUTE BRONCHOSPASM
- NOT for ACUTE. Maintenance - Increased bleeding risk w/ Coumadin and aspirin
A/E
- Headache >10%**
- dizziness, weakness
- GI
- Myalgias
- Fever
Leukotriene Modifiers
-Psych?
- In younger children, these meds can cause MOOD INSTABILITY** PSYCH
Leukotriene Modifiers
-Montelukast (Singulair)
- Adult: 10 mg
- Pediatric 1-5yrs: 4 mg
- 6-14 yrs: 5 mg
Caution with Pregnancy and Lactation
Often given at night**
Cromolyn
-Info
- Mast cell stabilizer
- Alt Therapy in children for step 2
- Prevents exercise induced asthma
MOA:
-Blocks chloride channels and modulate mast cell mediator release
Caution:
-Renal/hepatic impairment
A/E:
-Unpleasant taste, rash, sore throat, cough
Cromolyn
-Dosing
- Adult: 20 mg QID per nebulizer initially
- Pediatric: >2 yrs 20 mg QID per nebulizer initially
Pregnancy/Lactating: NO RISK**
Not used a lot in primary care*
Methylxanthines
-Info
- Alt treatment for adolescents and adults w/ mild persistent asthma
- MOA
- Inhibits phosphodiesterase, preventing breakdown of cAMP, causing smooth muscle to relax and preventing release of histamine and leukotrienes
Methylxanthines
-Contraindications & A/E’s
- Contraindicated in:
- Allergy to CORN products
- Not recommended <12 yrs
- Not for Acute asthma exacerbations
A/E’s
- Life threatening ARRHYTHMIA’S
- HA
- N/V/D
- restlessness, seizures & palpitations
Can Cause TOXICITY
Methylxanthines
-Exemplar Drug
- Theophylline is exemplar drug
- Max dose in adults 600 mg/day
- Avoid in pregnant women
- Monitor blood levels every 6 months for TOXICITY’S**
Methylxanthines
-Therapeutic Levels?
- Adults: 5-15 mcg/ml
2. Peds: 5-10 mcg/ml
LABA’s
-Info
- Used in combination w/ ICS for treatment of MODERATE PERSISTENT ASTHMA
- MOA
- Activates adenylate cyclase & ⬆️cAMP ➡️ relaxing smooth muscle and relieving bronchoconstriction
LABA’s
-Contraindication/Caution & A/E’s
Same cautions and A/E’s as SABA’s**
Ex:
-Ischemic heart dz, HTN, arrhythmia, seizures, hyperthyroidism
Caution w/:
-Tricyclics, MAO inhibitors; antagonized by beta blockers
A/E’s:
-Same as SABA’s
LABA’s
-How to Use?
- NEVER used as Monotherapy
- Used as adjunct with ICS**
- Does not replace ICS - NOT for acute exacerbations
- Can use ICS + formoterol (LABA) for ACUTE SYMPTOMS
LABA’s
-Black Box Warning
- Increase risk of asthma related death
ICS/LABA Combo Therapy?
- Advair (Fluticasone/Salmeterol)
- NOT used in pregnancy/lactation - Symbicort (Budesonide/Formoterol)**
- ICS/LABA Combo that can be used as MAINTENANCE or RESCUE per GINA guideline**
Proper Use of Inhaler
-Steps**
- Shake inhaler for 2-5 seconds
- If not used for >48 hrs, Prime the inhaler by depressing canister once
- Sit up straight or stand and breath out all the way
- Slowly breath in THEN depress canister once already breathing in
- Continue breathing in for 3-5 seconds until lungs are full - Hold breath for 10 seconds and wait 1 minute between puffs
- RINSE MOUTH then spit out
- Re-cap and store
Immunomodulators
-Exemplar/Info
- Omalizumab (Xolair) for SEVERE PERSISTENT ASTHMA
- MOA
- Prevents IgE from binding to mast cells and basophils leading to decrease mediators - NOT for acute attack
A/E’s
-Anaphylaxis, URI, headache, bruising at injection site
Should be prescribed and administered by specialist** NOT FOR PRIMARY CARE
Systemic Corticosteroids
-Info
- Treatment in ACUTE moderate/severe asthma exacerbation
- MOA
- Inhibit cytokine and mediator release, inhibit IgE synthesis
- Suppress inflammatory process & suppress airway inflammation and edema - Peak reached in 1-2 hrs
- 5 day-2 week coarse recommended
Systemic Corticosteroids
-Contraindications/Cautions?
- Untreated infection
- Lactation
- Alcohol intolerance
- DM w/ increase BG
- with quinolones- TENDON RUPTURE
Fluoroquinolones & Systemic Corticosteroids??
- Increase risk of TENDON RUPTURE
Systemic Corticosteroids
-A/E’S
- ANAPHYLAXIS
- Adrenal insufficiency
- Cushing’s syndrome
- Edema
- Hypokalemia
Systemic Corticosteroids
-How to administer?
- Short-course “BURST” treatment
- Adults:
- 40-60 mg daily for 5-14 days - Peds
- 1-2mg/kg/day divided QD-BID x 3-10 days - Can be administered w/out tapering
- Continue until peak expiratory rate is 80% or symptoms resolve
