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Obstructive lung disease Flashcards

1
Q

Asthma overview

A

Heterogenous disease w/ chronic REVERSIBLE inflammation of the airways
-traffic pollution 13% global asthma
Triggers: exercise, allergen irritant exposure, change in weather, laugher, or viral infection
Associated conditions: atopy (hypersens), obesity, GERD, OSA (obstructive sleep apnea)

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2
Q

Dx of Asthma- BEEPS

A

No Gold standard
-Blood tests-> eosinophilia, elevated IgE
-Spirometry w/ methacholine
-FEV1/FVC
-PEV
-Exercise challenge test- FEV1
-Chest XRAY exclusion

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3
Q

Tx depending on severity and classification

A

Children:
Intermediate: no night time
Mild: more than 2 days a week
Mod: daily symptoms
Severe: daily, nightly, and impair ADL

Adults:
intermittent: less than or equal to 2 days
Mild: over 2 days but not daily
Mod: Daily
Severe: throughout day w/ adl impairment

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4
Q

Lifestyle changes and preventative

A
  1. Physical activity, weight loss, smoking cessation, avoidance of irritants (cosmetology school), emotional stress
  2. avoid occupational exposure
  3. annual influenza and covid 10 vacc
  4. recommended pneumococcal vacc
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5
Q

asthma Tx overview

A

Intermittent: no daily control
1. Albuterol PRN rescue
2. PRN low-dose inhaled corticosteroid

Mild persistent:
1. Low-dose inhaled corticosteroid- daily
2. Albuterol PRN rescue
3. theophylline, mast cell stabilizer, or leukotriene modifier

Moderate persistent:
1. low-medium dose inhaled glucocort + Long acting inhaled beta agonist (LABA)
2. add LAMA
3. Albuterol rescue
4. theophylline, high dose inhaled glucocort, leukotrien mod

Severe:
1. High dose inhaled corticosteroid + LABA
2. theophylline and leukotriene
3. oral steroids
4. SAMA or LAMA

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6
Q

Bronchodilators

A

Beta3=2 agonist, Bronchoselective-> work w/ Calcium to produce SM relaxation
Short acting, water soluble: Isoproterenol, albuterol/levalbuterol
long, lipid soluble, more bronchoselective: Formoterol, salmeterol, indacaterol, olodaterol, vilanterol

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7
Q

Short acting bronchodilators

A
  1. Albuterol nebulized
  2. Albuterol MDI (ProAir HFA/ Proventil HFA/ Ventolin HFA)
  3. Levalbuterol nebulized (Xopenex)- twice as potent as albuterol
  4. Levalbuterol MDI (Zopenex HFA)

epi is a SABA- but alpha agonist as well so = whole body

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8
Q

Delivery devices

A

MDI- metered dose inhaler- 50% of med gets in
DPI- dry powder inhaler- 30% of med gets in
Nebulizers- 15%

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9
Q

MDI- test q

A

inspiratory: slow and deep, hold breath, priming and shaking bottle

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10
Q

DPI- test q

A

Deep forceful inhale= QUICK

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11
Q

Long-acting Bronchodilators

A

NEVER SOLO FOR ASTHMA PTS
LABAS = >12
1. Formoterol
2. Salmeterol
Ultra LABAs = >24
indacterol, vilanterol, olodaterol

SE: asthma related death, bronchospasm, asthma exacerbation, anaphylaxis, HTN, angina, cardiac arrest, arrhythmia, hypkalemia, hypotension, hyperglycemia

HIGHER MORTALITY IF USED SOLO

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12
Q

Why are corticosteroids so important in asthma? HERM

A

TO START EARLY
1. Increasing # of Beta 2 adrenergic receptors and improving the receptor responsiveness to beta 2 adrenergic stimulation
2. Reduce mucus and hypersecretion
3. Reduce bronchial hyperresponsiveness (wheezing, breathlessness, chest tightness, coughing)
4. Reduce airway edema and exudation

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13
Q

Systemic corticosteroids

A
  1. all pts w/ acute severe asthma exacerbation not responding to inhaled cortic
    -START W/IN 1 HR OF ED SETTING TO REDUCE HOSPITALIZATION
    -ADULTS 5-7 DAYS OR KIDS 3 DAYS
  2. tapering unnecessary after improvement IF CONTINUING INHALED CORTICOSTEROIDS

1 burst in ED-> 8 burst of prednisone is equal to steroids every other day for a year= effect on bones & SE

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14
Q

Inhaled corticosteroids

A

Most improve in first 1-2 wks-> max improvement in 4-8 wks
-improvement in baseline FEV1 and PEF @ 3-6 wk mark
Dosing:
mild: once a day
Mod: twice
Severe: multiple daily

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15
Q

Anticholinergics- Reverse Bronchoconstriction

A

MOA: inhibitors of muscarinic receptors
1. Ipratropium bromide= nonselective antagonist of M1, M2, M3 receptors-> ADJUNCT THERAPY in acute severe asthma-> inhaled in ED to reduce hospitalizaiton
2. Tiotropium Bromide-> higher affinity for muscarinic receptors and dissociates more slowly-> long acting, duration of 24 hrs

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16
Q

Leukotriene modifiers- block synth of leukotrienes

A

reduce: allergen, exercise, cold air hypervent, irritant, and aspirin induced asthma
IMPROVE PULMONARY FXN TESTS (FEV1 AND PEF)-> DECREASE NOCTURNAL AWAKENINGS AND bETA 2 AGONIST USE AND IMPROVE ASTHMA SYMPTOMS
1. Montelukast (singulair)- Cysteinyl leukotriene receptor antagonist
2. Zafirlukast- cysteinyl leukotriene receptor antagonist
3. Zileuton- one 5-lipoxygenase inhibitor-> MAJOR high Liver enzymes and drug interactions w/ CYP

SE: CHURG-STRAUSS SYNDROME= asthma/hayfever, EOSINOPHILIA-> CAUSE OR MASK ASTHMA?, neuropsychiatric AE (CHILDREN AGGRESSIVENESS, IRRITABILITY, SLEEP DISTURBANCE), hepatic dysfxn/failure

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17
Q

Biologics

A
  1. Anti-IgE- Omalizumab (Xolair)
    2.Anti-IL 5 Mepolizumab (Nucala), Reslizumab (Cinqair), Benralizumab
  2. Anti-IL4/IL13 Dupilumab (Dupixent)
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18
Q

Children and Pregnancy

A

Children: Montelukast-> double dose instead of adding LABA
Pregnancy: Budesonide
MG sulfate- Magnesium-> iv or nebul for kids= SINGLE 2 G IV INFUSION UPON ED ARRIVAL
Theophylline- rarely used due to the high risk of severe life-threatening toxicity (n/v, tachy, abd pain)
Ketamine-for intubation asthmatic pts-> inhibit histamine and acetylcholine-induced bronchoconstriciton

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19
Q

Status asthmaticus or Severe Asthma Attack- BOSE MK

A
  1. Beta 2 agonists and steroids
  2. O2
  3. Oral steroids
  4. Epinephrine (if due to anaphylaxis)
  5. IV or Nebulized MgSO4
  6. Ketamine if intubation
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20
Q

COPD

A

Defined: presence of CHRONIC AIRFLOW OBSTRUCTION, determined by spirometry that usually occurs in the setting of noxious environmental exposures- MC CIGARETTE SMOKING- but doesnt have to smoke
- combo of emphysema, chronic bronchitis, small airway disease-> NOT REVERSIBLE
Sxs: cough, sputum production, dyspnea
HALLMARK: REDUCTION IN FEV1 AND FEV1/FVC
Guidelines: test for ALPHA-1 AT DEFICIENCY IN ALL SUBJECTS W/ COPD or asthma w/ chronic airglow obstruction

pfts to diagnose staging

21
Q

Asthma vs COPD

A

Asthma
-recognized
-dyspnea w/ bronchospasm
-FULLY REVERSIBLE w/ bronchodilators
-NOT GENERALLY PROGRESSIVE except in more severe
-frequent change in status

COPD
-underrecognized/undertxt
-dyspnea w/ exertion
-RESPONSIVE BUT NOT FULLY REVERSIBLE W/ BRONCHODIL
-PROGRESSIVE OVER TIME
-no changes over time except for progression

22
Q

nonpharm therapy

A
  1. SMOKING CESSATION-> WILL STOP COPD PROGRESSION
  2. limit environmental hazards and airborne exposures
  3. Pulmonary rehab- exercise training, even high intensity
  4. Long-term oxygen therapy-> resting PaO2 under 55, lower mortality if atleast 5 years of use, Nasal cannula at 1-2 l/min
  5. Vaccines: influenza, covid, PPSV23, PCV13
23
Q

Gold criteria- COPD diagnosis

A
  1. FEV1>80 = 0-1 exacerbations per year
  2. FEV1>50 but <80 = 0-1 exacerbations per year
  3. FEV1>30 but <50 = >2 exacerbations per year, or 1 hospitalizations
  4. FEV1<30= <2 exacerbations per year and <1 hospitalizations
24
Q

COPD tx

A
  1. SABA PRIN and Anticholinergic PRN
  2. LABA or LAMA and SABA PRN
  3. Inhaled corticosteroid plus LABA or LAMA, supplemental oxygen, pulmonary rehab, SABA PRN, LAMA+LABA
  4. Inhaled corticosteroid plus LABA, LAMA, pulmonary rehab, supplemental oxygen, LABA/LAMA combo, LAMA/LABA/ICS triple combo, continuous Azithromycin

NEVER USE CORTICOSTEROID ALONE= COPD
NEVER LABA= ASTHMA

25
COMBOS- pick one w/ lowest dose & work up
26
Phosphodiesterase inhibitors PDE4
PDE4 found in airway sm cells, inflam cells, responsible for degrading intracellular cAMP 1. Roflumilast -for pts w/ recurrent exacerbations despite tx w/ triple therapy or pts who are on dual therapy and not a candidate for ICS -DO NOT GIVE IN CONJUNCTION W/ THEOPHYLLINE -SE: DIARRHEA, NEUROPSYCHIATRIC (suicide, insomnia, anxiety, depression) -low and slow -drug interactions: CYP p450
27
Azithromycin
250 MG daily chronic tx- lower rate of exacerbations-> improved quality of life scores Drawbacks: hearing deficits, colonization of macrolide resis bacteria, QT prolongation ADD AZITH FOR PTS W/ RECURRENT EXACERBATIONS DESPITE OPTIMAL THERAPY AND ARE NOT ACTIVE SMOKERS
28
other pharm therapies
1. alpha trypsin replacement therapy- for INHERITED AAT deficiency associated emphysema-> weekly infusions of pooled human AAT to maintain levels over 10 micromole/L-> expensive 2. Expectorants and mucolytics-> high dose to be effective 3. Opioids-> morphine to relieve dyspnea in pts w/ end-stage COPD
29
Lung section
here we go
30
Infections of lung and resp system
1. acute epiglottitis 2. Croup 3. Bronchiolitis 4. Pertussis 5. Pneumonia 6. Tuberculosis 7. COPD exacerbation
31
Acute epiglottitis
Risk: non-vacc kids Organism: H. flu -> get vacc Sxs: muffled voice, tripoding, drooling, fever, distress Xray: thumb sign Complications: severe life-threatening due to risk of sudden airway compromise-> secure airway tx: 1. secure airway 2. 3rd gen Cephalosporin (ceftriazone) + antistaph (vancomycin)
32
Laryngotracheobronchitis aka Croup
risk: kids organism: Parainfluenza sxs: seal bark cough that improves w/ exposure to cold air, URI sxs with STRIDOR, congestion, URI Xray: Steeple sign complications: respiratory failure Tx: 1. mild - humid air/symptomatic care + dexamethasone 1 dose 0.6 mg/kg max of 12 mg 2. Mod- steroids, dexa IV, IM, PO 3. Severe- racemic epinephrine (Nebulized)- only if resp failure, STRIDOR @ REST-> MUST WATCH FOR 2-3 HOURS BC REBOUND EFFECT Westley croup severity score: stridor, retractions, blue lips
33
Bronchiolitis
risk: kids 2 and younger organism: RSV sxs: URI sx w/ fever and wheezing, nasal flaring, tachypnea, retractions, low O2 stats, move to LRI Tx: NO STEROIDS -mild: hydration, NASAL SUCTION BULB, monitor -Mod to severe: nasal suction, hydration, oxygen, one time trial of inhaled bronchodilators, do not use oral glucocort
34
Pertussis aka Whooping cough
organism: Bordetella pertussis Sxs: prolonged cough >2 weeks, inspiratory "whoop" w/ paroxysmal cough, pot-tussive emesis tx: reduces spread - doesnt shorten the course -azithromycin if onset of cough w.in past 6 wks - and if onset w/ in 3 wks no abx if no onset of cough Immunization: younger kids: DTAP- diphtheria toxoid, tetanus toxoid, the pertussis vaccine -> 5 dose series= 2, 4, 6, 15-18, and 4-6 yrs of age older kids: TDAP- tetanus toxoid, reduced diphtheria toxoid, pertussis single boost from 11-12 and every 10 year intervals
35
Pneumonia
1. Community-Acquired pneumonia 2. Hospital-acquired pneumonia 3. Ventilator-associated pneumonia
36
CAP empiric tx outpatient
comorbities: -penicillin allergy= cephalosporin + macrolide -no pen allergy= Augmentin plus azithro -no allergy but COPD= Fluoro No comorb: 5 days tx penicillins, augmentin, macrolides, tetracyclines,
37
HAP or VAP tx
hap= occurs after 48 hrs or more after admission not at admission vap= type of HAP develops more than 48 hours after endotracheal intubation tx: recent abx use? resident flora and resis rates in hospital or ICU-> sputum cultre increased mortality-> underlying diseases or severity of illness available cultures or gram stains? risk for MRSA or MDR - multidrug res recommended tx: Piperacillin-tazobactam Cefepime Levofloxacin Imipenem Meropenem
38
Special Pneumonia
fungal: histoplasmosis or blastomycosis -> tx: Itraconazole or alt amphotericin B HIV related: pneumocystitis jirovecii -> tx: Bactrim x 21 days
39
Pneumonia vaccines
indications: >65 yoa 19-64 yoa w/ chronic heart, lung, liver disease, immunocompromised, or impaired splenic fxn 2 vacc: Pneumococcal polysaccharide vaccine (PPSV)- Pneumovax Pneumococcal conjugate vaccine (PCV)- Prevnar Prevnare 1 yr then Pneumovax
40
PPSV
IM or SQ 1 dose 23- valent pneumococcal polysaccharides AB response wanes over time-> pt may need revacc depending on comorb EVERY 5-10 YRS
41
PCV
IM Prevnar13 mc-> 13 capsular types linked to protein-> helps body to produce ab 4 dose series after birth- 2, 4, 6, 12-15 months
42
TB tx review
Latent tb- short course of rifamycin based 2-4 month regimen active tb- rifampin, isoniazid, pyrazinamide, ethambutol prego? NO STREPTOMYCIN, PYRAZINAMIDE
43
COPD exacerbation overview
tx settings: outpatient or inpatient RF for poor clinical outcomes: -comorb conditions: HF, ischemic heart disease, uncontrolled HTN, uncontrolled lipidemia -severe underlying COPD (PEV1 <50%) - >2 exacerbations per yr -hospitalization for an exacerbation in past 3 months - receipt of continuous O2 - >65 yrs Ris for infection w/ Pseudomonas: -chronic colonization or previous isolation of pseudomonas from sputum -very severe COPD (FEV1 <30%) -Bronchiectasis on chest imaging -broad spec abx use in past 3 months -chronic systemic glucocort use
44
COPD exacerbation empiric tx- Outpatient
target: haemophilus influenzae, moraxella catarrhalis, streptococcus pneumoniae 1. No RF of poor outcomes or pseudomonas -Macrolide - azithromycin, clarithromycin -2nd or 3rd gen cephalosporin- cefuroxime, cefpodoxime, cefdinir 2. RF for poor outcome, NO risk pseudomonas: -Augmentin -resp fluoroquinolone 3. RF for both: Ciprofloxacin Duration: tx for 5 days
45
COPD exacerbation empiric tx- Inpatient
target: coinfections of previous organisms, atypical bacteria, resistant bacteria 1. No risk for pseduomonas- OR -respiratory fluoroquinolone -3rd gen cephalosporin- ceftriaxone or cefotaxime 2. risk for pseudomonas- all ORs -Cefepime -ceftazidime -Pipercillin- tazobactam tx: 5-7 days other considerations: -greater than or equal to 2 exacerbations-> may consider MACROLIDE PROPHYLAXIS -Azithromycin= daily if exacerbations
46
Effects of smoking
Damaging effects to nearly every organ of the body LEADING CAUSE OF PREVENTABLE disease, disability, and death in US 3 leading: 1. lung cancer 2. chronic obstructive pulmonary disease 3. ischemic heart disease
47
Nicotine effects on the body
blood- increase clotting Lungs- bronchospasm Muscular- tremor, pain GI- nausea, dry mouth, dyspepsia, diarrhea, heartburn Joints- pain Central- lightheadedness, headache, sleep disturbances, abnormal dreams, irritability, dizziness Heart: increased or decreased HR, increased BP, tachycardia, more or less arrhythmias, coronary artery constriction Endocrine- hyperinsulinemia, insulin resistance
48
Why is it difficult to quit?
1. Nicotine stimulates DOPAMINE in the "reward" center-> feeling of pleasure and relaxation 2. CAN DEVELOP WITHDRAWAL SYMPTOMS W/IN 24 HOURS-> PEAK W/IN FIRST 3 DAYS AND MAY TAKE WEEKS TO SUBSIDE quickly reversed w/ nicotine
49
Questions:
tx of acute exacerbation of COPD= SABA good outcome of pharm in chronic COPD= REDUCE EXACERBATIONS MDI-> DPI= rapid forceful inhalation Gold stage 1 pharm strategy= Bronchodilator lower risk of exacerbation COPD= LAMA Roflumilast PE= PDE 4= SE= GI nausea lower progressive decline in fxn= SMOKING CESSATION

Pharm 2 (15 decks)

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