Nurs 605 Module 16 Flashcards
What is asthma? What are the clinical manifestations of asthma?
chronic inflammatory airway disease
wheezing, SOB, chest tightness, cough, varies in intensity
Identify some differences between asthma and COPD
asthma: early onset, not caused by smoking, infreqeunt sputum, normalizes, stable
COPD: later onset, causal relationship with smoking, frequent sputum production, not stable, can worsen with time
What are some non pharmalogical approaches to preventing COPD and asthma?
smoking cessation physical activity avoid triggers avoid ASA, NSAIDs pnuemoccocal and influenza vaccines
What are the risk factors for developing COPD?
smoking air pollution occupational repeated infections genetics
How do you diagnose COPD
spirometry (FEV <0.7)
radiograph of chest
What are the main classes of pharmacological options for asthma? Name some common drugs in each class
inhaled corticosteroids (ICS) qvar, pulmicort (budesonide), flovent (fluticasone)
ICS/long acting bronchodilator (ICS/LABA)- symbicort, advair, breo
leukotriene receptor antagonists (LTRA) -singular(montelukast)
Short acting beta 2 agonist (SABA) -ventolin salbutamol
What is the MOA of ICS? common side effects? important patient information?
decrease mucous production
decrease inflammation
s/e: thrush, sore throat, drymouth
rinse mouth after use
What is the MOA of ICS/LABA? side effects? important patient information?
decrease mucous production
decrease inflammation and bronchoconstriction
s/e: tachycardia, headache, cramps
LABA cannot be used as monotherapy in asthma
cannot abruptly stop, must taper
What is the MOA of SABA? common side effects? important patient information?
relieves bronchocontriction
PRN use only
s/e: tremor, tachcardia, nervousness, palpitations
always use in rescue plan
Describe the step up or step down approach in patients with asthma
• Rescue inhaler (PRN SABA) 100mcg 1-2 puffs TID-QID
• Low regular dose ICS plus SABA 50-100mcg BID
• ICS/LABA combo plus SABA- low dose 100/6mcg 1-2 puffs BID
• ICS/LABA combo plus SABA-medium dose 200/6 1-2 puffs BID
• Controlled? Step down the approach
increased use of SABA means therapy ineffective, step up approach
Describe the essential messages of patient education for asthma care
- smoking cessation
- physical activity
- avoid triggers
- avoid ASA, NSAIDs
- pnuemoccocal and influenza vaccines
Recommend appropriate immunizations for the patient with COPD.
- Annual flu vaccine
- Pneumococcal vaccine- evidence mixed, but safer to give anyway
- One, and then another 5 years later
Outline medication management for mild/stable COPD
- SAMA (ipotropium) or SABA is appropriate first line therapy
- Both are effective, not one is superior to the other
- If symptoms worsen, can use as a combination of both (combivent)
- Relieves dyspnea
- Preferred over oral corticosteroids
Outline medication management for moderate COPD
- Moderate COPD
- Increasing exacerbations or dyspnea
- Can add a LAMA (tiotropium) or LABA (salmeterol)
- Evidence does not show which is superior to the other
- LAMA for those who are have increasing exacerbations -group c
- Combo therapy can be used (inspiolto) but little evidence to prove superiority
Outline medication management for severe COPD
- Severe COPD
- Triple therapy may be needed
- LABA, LAMA + ICS
- ICS is reserved for very severe COPD due to increased risk of pneumonia
- May be used in those that have uncontrolled exacerbations despite adequate bronchodilator therapy
Describe the stages of change as they relate to motivational interviewing.
- Relevance – how is this relevant to the patient? d/c smoking=better health outcomes etc
- Risks- short term and long term risks of not quitting
- Rewards-benefits of smoking cessation-tailor to patient
- Roadblocks- what have they tried, what worked and dint’ work
- Repetition/encouragement-repeat above, encourage to stop
Describe the drug therapies available to assist clients in smoking cessation.
- Nicotine replacement therapy
- Patch, gum, lozenges and inhalers
- Patch- transdermal nitcoine delivery
- Gum-chew, park,
- Lozenge- suck, do not chew or swallow
- Inhaler- provides hand to mouth motion
- Buproprion (Wellbutrin, zyban)
- Varenicline (champix)
What is the MOA of bupropion? side effects? contraindications?
- inhibits reuptake of dopamine, serotonin, norephinephrine
- S/E: insomnia, agitation, dry mouth, nauseas, seizures (rare)
- Contraindications: not to be used in those with hx of seizures or active seizures
- Start 2 weeks prior to quit date,
- Ok to use in combo with other NRT products
What is the MOA of varenicline? side effects? contraindications?
- Varenicline – Champix
- Nicotine receptor partial agonist
- S/E: nausea, sleep disturbances, vivid dreams., headaches, impaired ability to operate machinery, depression mood; suicide and suicidal ideation (but no cause and effect link has been found!)
- DO NOT COMBINE WITH OTHER NRT-can increase risk of adverse effects
What are the clinical manifestations of conjunctivitis?
• Conjunctivitis: normal pupils, redness, lid swelling, discharge or watery mucoid, conjunctival edema
What are the recommended therapies for conjunctivitis?
- Opthamlic abx- not one is better than another; bexifloxacin, moxifloxacin, cipro eye drops
- Viral conjunctivitis- ophthalmic lubricants
- Refresh, natural tears etc.
- Both self-limitiing, no improvement abd 4-5 days with abx therapy-refer to opthamologist
List the recommended therapy for a child with croup
- Oral dexamethasone 0.15mg-0.60mg/kg
- Oral not tolerated? Nebulized budesonide
- Severe croup- nebulized epinephrine 1:1000 5mL
What are the clinical manifestations of croup?
- Common in children- 6mos-3 years, can affect up to 15 years of age but rare
- Caused by upper airway obstruction, viruses is most common cause
- Seal like cough, stridor, worsens at night, ok during the day, fever, rhinorrhea
Pharm management of allergic rhinitis
- Saline rinses, nose sprays to decrease congestion
- Eye drops to alleviate itching eyes
- Antihistamines
- Loratadine
- Cetirizine- sedating at higher doses
- Older gen. antihistamines can cause sedation
- Decongestants
- Nasal sprays, intranasal corticosteroids- fluticasone, budesonide
- Oral decongesntats
- Topical nasal corticosteroids
- Eye drops-olopatadine
- Immunotherapy-allergy shots
Non pharm management of allergic rhinitis
- Non pharm:
- Avoid irritants and triggers
- Air conditioning
- Remove pets to reduce dander
List medications which should be avoided or are contraindicated in a patient with glaucoma.
- Antihistamines
- Anticholinergic drugs
- COPD ipratroprium
- Incontinent drugs
- Anti-depressants
- Ephedrine- OTC cold and flu
Describe the reason for limiting the duration of nasal decongestants and recommend a management plan for a patient suffering from rebound congestion.
- Nasal decongestants- >3-5 days use can cause rebound congestion
- Mitigated with nasal corticosteroids
- If using topical nasal corticosteroids as monotherapy increases risk of rebound congestion
Outline a management plan for a patient with acute asthma.
- Worsening can be life threatening
- SABA 2-6 puffs q 20 min x 1 hour until stabl
- Unstable? Oral corticosteroids
- Revisit/modify plan
- Assess compliance, technique, triggers, lifestyle
Which medications are first line in COPD and asthma?
COPD-SAMA/SABA; LAMA
Asthma- SABA; ICS
ICS last line in COPD due to steroids increasing risk of pneumonia
What is the pro and con of a MDI? metered dose inhaler?
dexterity and coordination
not all devices have counters
more effective with spacer-bulky
What are the pros and cons of a diskus?
dry powder inhalation
more costly than MDIs
bulky
What are the pros and cons of turbohalers?
dry powder device
dose counter despite being empty
small amount, patient may not feel the dose
avoid overdosing
What are the pros and cons of twisthalers?
dry power device
twist caps
dexterity
What are the pros and cons of handihaler?
dry powder
capsules
many steps, needs lots of dexterity
not good for cognitive concerns
What are the pros and cons of ellipta?
expires within 6 weeks of package
PRN dose of SABA
low 100mg TID-QID
In the step wise approach for asthma, when is it appropriate to add a LABA to the therapy?
ICS dose isn’t effective
can add LABA but must be combined
Discuss LTRA and their use in astham
monotherapy is not as effective as ICS therapy
s/e: headache, abdominal pain, fly like symptoms and diarrhea
Discuss the components of dx of COPD
- smoker
- > 40 years of age
- syptoms: cough, SOB, wheeze, persistent colds, URTI
- FEV1 <0.7 with short acting bronchodilator
What is the MOA of SAMA? side effects? dosing?
ipratropium-binds to muscarinic receptors to prevent bronchoconstriction
dosing: 2-4 puffs q6h
used for chronic symptoms
What is the MOA of LAMA? side effects? dosing?
tiotroprium- selective for M1 and M3 muscarinic receptors
s/e: metallic taste, glaucoma in eyes, more dry mouth, urinary retention
dosing: 18mg inhaled and once daily
Who should use caution in use of LAMA?
cardiovascular cautions
MI in past 6 months
unstable cardiac dysrythmmias
heart failure
What would be the pharmaceutical choices for patients with frequent COPD exacerbations?
- LAMA over LABA
- LAMA + LABA
- LAMA+LABA+ICS
Discuss the management of acute exacerbation in COPD
increase use of short acting bronchodilator
oral prednisone as last choice (30-50mg daily x 5-14 days)
abx: only if increasing sputum, purulence and dyspnea
