Module 5: Respiratory (b) Flashcards
Asthma Management
-Step 1
- PRN SABA
AND - At the start of RTI: Add short course of daily ICS
Asthma Management
-Step 2
- Daily low-dose ICS & PRN SABA
Alternative:
-Daily Montelukast or Cromolyn & PRN SABA
Asthma Management
-Step 3
- Daily medium-dose ICS and PRN SABA
Asthma Management
-Step 4
Daily medium dose ICS-LABA & PRN SABA
Alternative:
-Daily medium dose ICS + Montelukast & PRN SABA
Asthma Management
-Step 5
- Daily high-dose ICS-LABA & PRN SABA
Alternative:
-Daily high-dose ICS + Montelukast & PRN SABA
Asthma Management
-Step 6
Daily high-dose ICS-LABA + oral systemic corticosteroid and PRN SABA
Alternative:
-Daily high-dose ICS + Montelukast + oral systemic corticosteroid & PRN SABA
Classification of Asthma Severity
-Changes from 0-4 yrs to 5-11 years
Charts are identical for both age groups with one addition
-5-11 year olds have LUNG FUNCTION tests for FEV/FVC rations
Classification of Asthma Control
->/= 12 years old Difference?
- Can use a validated questionnaire
COPD
-Definition
- Chronic lung dz characterized by small airway obstruction and reduction in expiratory flow rate.
- Spirometry required to make diagnosis
- FEV/FVC <0.70 confirms airflow limitation
COPD
-Goals of Therapy
- Reduce Symptoms
- Relieve symptoms
- Improve exercise tolerance
- Improve health status - Reduce Risk
- Prevent Dz progression
- Prevent/treat exacerbations
- Reduce mortality
COPD
-Pharm Therapy for Maintenance?
- SABA’s and LABA’s
- Anticholinergics/Antimuscarinics (short and long acting)
- Phosphodiasterase-4 inhibitors
- ICS
COPD
-Pharm Therapy for Exacerbations?
- Short-acting bronchodilators
- Systemic corticosteroids
- Antibiotics
COPD
-LABA’s?
- Salmeterol (Serevent)
- 50mcg/actuation
- Adults: 1 puff q12 hrs - Formoterol (Performist)
- 20mcg/2 ml neb
- Adults 20 mcg per neb q12 hr (max 40 mcg daily)
LABA monotherapy is okay with COPD but NOT with Asthma
-NOT for Pregnancy/Lactation
COPD
-Antimuscarinic Antagonists?
- MOA
- Relax bronchial muscles causing Bronchodilation; decrease mucous production. - Contraindication/Caution
- Allergies to atropine, soy, peanuts
- Not for Acute Bronchospasm
- Caution in narrow-angle glaucoma, BPH, pregnancy and lactation - A/E’s
- restlessness, dizziness, HA, GI, blurred vision, cough, urinary obstruction
COPD
-Short-Acting Antimuscarinics?
- Ipratropium (Atrovent)
- Available as neb or inhaler
- Caution in pregnancy/lactation - Combivent (Ipratropium/Albuterol)
-Caution in pregnancy/lactation
—Albuterol can reduce uterine contractility**
COPD
-Long-Acting Antimuscarinics
- Tiotropium (Spiriva)
- Delivery takes a lot of coordination d/t needing to put in and puncture med capsule
- Not good for elderly with poor fine motor control** - Aclidinium (Tudorza)
- Need to be able to take a BIG DEEP breath in. Click heard when med is delivered - Caution in pregnancy/lactation
COPD
-Phosphodiesterase-4 Inhibitors (PDE4)
- Roflumilast (Daliresp) 500mg pó daily
- Indicated for SEVERE COPD associated with recurrent exacerbations
- Contraindication/Caution
- Hepatic impairment
- Caution w/ depression, and SI - A/E’s
- Diarrhea, nausea, weight loss, HA, back pain, dizziness, loss of appetite - Caution in pregnancy/lactation
Assessment of COPD
-Grading?
GOLD 1 = FEV >/= 80
GOLD 2 = FEV 50-79
GOLD 3 = FEV 30-49
GOLD 4 = FEV = 30
COPD
-How to classify?
- Spirometry shows the Grade (GOLD 1-4)
2. Group is based on symptoms and exacerbations (Group A-D)
COPD Treatment
-Group A
This patient is LESS symptoms and LOWER risk*
- Short-acting antimuscarinic SAMA
- Short acting beta agonist SABA
COPD Treatment
-Group B
This patient is LOW Risk and MORE symptoms
- LAMA or LABA
- both with severe breathlessness **
COPD Treatment
-Group C
This patient is LESS symptoms and MORE risk
-Pt has had >/= 2 exacerbations or been hospitalized
- LAMA
COPD Treatment
-Group D
- LAMA
Or - LAMA + LABA (For Highly symptomatic pt’s with CAT > 20
Or - ICS + LABA (If eosinophil >300 or hx of asthma)
COPD
-Pharm Mgmt Follow up
- Review: symptoms (Dyspnea) and exacerbation risks
- Assess: inhaler technique and adherence
- Adjust: pharm treatment, including escalating or de-escalating
Follow-up Pharm Management
-Persistent Dyspnea
- Persistent Breathlessness or Exercise Limitation on Monotherapy?
- Two Long-acting bronchodilators recommended - Persistent Breathlessness or Exercise Limitation on ICS/LABA?
- Add a LAMA - If symptoms still progress, INVESTIGATE other causes
Follow-up Pharm Management
-Exacerbations continuing?
- Consider a LABA/LAMA or LABA/ICS combo if on mono-therapy
- LABA/ICS for hx of asthma or Eosinophils >300 - On LABA/LAMA
- escalate to LABA/LAMA/ICS (with eosinophils >300)
- Or add Roflumilast
- Or azythromycin for (Former smokers) - On LABA/LAMA/ICS
-Add Roflumilast
Or
-Azythromycin if former smoker
COPD Exacerbations
-Presentation
- Increased airway inflammation and increased mucous production
- Symptoms:
- Dyspnea
- Increased sputum purulent and volume
- Increased cough and wheeze
COPD Exacerbations
-Classifications
- Mild
- Treated w/ Short-acting bronchodilators - Moderate
- Treated w/ Short-acting bronchodilators + Antibiotics and/or oral corticosteroids - Severe
- Requires hospitalization or ER visit
- May be associated w/ Acute Respiratory Failure
Management of COPD Exacerbations?
- O2 if spo2 is = 88%
- Bronchodilators: SABA + SAMA (DuoNeb)
- Systemic Corticosteroids
- Prednisone 40 mg daily x 5 days
- Recommended for pt’s w/ exacerbations more than mild severity - Antibiotics
- Increased dyspnea, volume of sputum or smoker hx
- AUGMENTIN, Macrolides or tetracycline 5-7 day course
Management of COPD Exacerbations?
-Antibiotics?
- AUGMENTIN
- Macrolides
- Tetracycline
5-7 day course
Acute Bronchitis
-State
- 95% of acute bronchitis caused by viral infections
- Evidence for cough suppressants is controversial
- NO ANTIBIOTICS**
CAP
-Stats
- S. Pneumonia MOST COMMON pathogen
2. Amoxicillin, doxycycline, fluoroquinolones are agents of choice
CAP Treatment
-No Comorbidities w/ NO recent antibiotic use?
- Amoxicillin 1 Tm TID x5-7 days
2. Doxycycline 100 mg BID x 5-7 days
CAP Treatment
-Co-morbidities or antibiotic use in past 3 months?
- Levaquin 750 mg daily x5 days
- AUGMENTIN BID or Cefpodaxime or Cefuroxime
PLUS
Azithromycin Or Clarithromycin 5-7 days
CAP
-Children Under 5 yrs?
- Bacterial Pneumonia
- Amoxicillin
- Azithromycin - Infant 4-16 wks w/ suspected chlamydial PNA
-Azithromycin 3 days
OR
-Erythromycin 14 days
TB
-First Line Drugs?
- TB requires multi-drug regimen over 9 months.
- Initiation phase is first 2 months followed by continuation phase for 4-7 months.
Meds:
- Isoniazid
- rifampin
- rifabutin
- rifapentine
- Pyrazinamide
- Ethambuton
TB
-Second line Drugs?
- Cycloserine
- Ethionaminde
- Moxifloxacin
- Gatifloxacin
COVID-19 Referrals
-Monoclonal Antibody infusion/injection
- Indicated for 12 years and older PLUS
- Treatment in high-risk individuals
- Prophylaxis in High-risk individuals - Give to individuals who are:
- High risk + Not vaccinated or immune-compromised
- No pre-exposure indication for treatment
- NOT a substitute for vaccination
COVID-19
-Things to avoid in clinic?
- Avoid nebulizer in clinic d/t spreading particles
2. Avoid Spirometry w/ confirmed or suspected COVID 19
