PHAR 721 Flashcards
Chronic Bronchitis occurs in patients with _________________? What time period defines chronic bronchitis?
COPD
Lasts longer than 3 months in each of 2 consecutive years
What is acute bronchitis?
A self-limiting cough that persists more than 5 days. Involves bronchi inflammation and is usually viral.
Also one of the most common reasons for a primary care visit (14 million cases annually)
What are the 2 causes of acute bronchitis, with examples from each?
Viruses (over 90 percent)
>influenza A and B
>parainfluenza
>rhinovirus
Bacterial
>Chlamydia pneumonia
Signs/symptoms of Acute Bronchitis
Cough (productive, persists more than 5 days and lasts 1-3 weeks)
Associated with prior upper respiratory infection, so make sure to get full PMI.
Wheezing, of Bronchi.
What signs/symptoms AREN’T typically associated with Acute Bronchitis?
Fever over 100, systemic symptoms, consolidation or crackles (aka rales)
How is acute bronchitis treated?
Symptoms are treated:
>cough suppressants at night (dextromethorphan)
>expectorants (Guaifenisen, although not much evidence)
>beta-2 agonists if wheezing (helps with bronchodilation)
>high-dose inhaled corticosteroids in emergency
Alternative therapies include echinacea for cold “prevention”, pelargonium and honey
How prevalent is the flu?
65.5/100,000 hospitalized in 2014-15 flu season, with highest rates occurring in those over 65. 141 pediatric deaths in same season.
How does flu present?
Influenza like illness (fever over 100, cough and/or sore throat without a known cause)
Describe the 2014-15 influenza virus
Influenza A: 83.5% (99.6% H3N2, 0.29% H1N1)
Influenza B: 16.5%
How many influenza viruses does the CDC characterize?
355 influenza viruses, characterized antigenically or genetically
High Risk Groups for Flu
Those over 65 or under 5, pregnant women, those with medical conditions (asthma, diabetes, heart disease, stroke, HIV or AIDS, cancer)
How the flu is spread and how long it lasts
Large particle respiratory droplets can fly 1-2 meters and contaminate surfaces (hard, non-poris with high humidity are the most habitable for virus).
Viral shedding occurs 1 day before symptoms and can last from 5 to 10 days after symptoms onset.
Incubation is 1-4 days, with 2 being the average.
Duration is typically 3-7 days, although cough and malaise may persist for 2 weeks.
What are the flu FACTS?
Fever, Aches, Chills, Tiredness, Sudden Onset
Flu Symptoms
Fever, nonproductive cough, myalgia, malaise (ill feeling), headache, sore throat, rhinitis is possible
Describe the different methods of flu diagnosis
Rapid influenza diagnostic test (takes less than 30 minutes, is 90% specific and 50-70% sensitive)
Viral cell culture (takes anywhere from 1 to 10 days)
Immunofluorescence (antibody stain) (takes 1-4 hours)
RT-PCR (1-6 hours)
What do we primarily use for flu diagnosis? What’s the downside?
Nasopharygeal swab
Unpleasant and false-positive
Flu complications
Pneumonia, bronchitis, sinus infection, ear infections, worsening of chronic conditions
Flu treatment options
Neuraminidase inhibitors (start within 48 hours)
What are 3 of the common neuraminidase inhibitors used?
Oseltamivir (Tamiflu) - 75 mg po bid for 5 days
Zanamivir (Relenza) - 10mg inhaled bid for 5 days
Peramivir (Rapivab) - 600mg IV as a single dose
Flu Prevention
Seasonal vaccine is best.
Other measures: >avoid ill people >frequently wash hands >avoid touching eyes, nose and mouth >cover nose and mouth when sneezing or coughing
Types of pneumonia (based on how illness is acquired)
Hospital acquired (HAP) - highly resistant Community acquired (CAP) Nonhospitalized patient with extensive healthcare contact (HCAP)
Describe CAP (Community acquired) Risk Factors
Chronic lung disease, cigarette smoking, dementia, stroke or brain injury, immune deficiency, heart disease, diabetes or cirrhosis, recent surgery
Symptoms and Signs of CAP
Cough (rust colored, mucopurulent), fever, chills, dyspnea, lung exam yields crackles or consolidation.
Others include chest pain, malaise, headache, confusion
Define crackles or consolidation (at they pertain to the lungs)
Crackles are a result of fluid in the lungs
Consolidation is result of large fluid presence preventing air movement
What 2 systems are used for CAP prognosis?
Pneumonia Severity Index (PSI) - predictive tool
CURB-65 (1 point given for each component)
>confusion
>urea (blood urea nitrogen above 7mmol/L)
>respiratory rate over 30
>BP (systolic under 90 and diastolic under 60)
>over 65 years of age
What do the results of a CURB-65 mean?
0-1 outpatient; 2 hospital; 3 or greater ICU
CAP causes
Bacteria are most common (streptococcus, mycoplasma and chlamydia [pneumoniae])
Viruses can include influenza, parainfluenza, respiratory syncytial virus
CAP treatment
Antibiotics for 5 days (macrolides common; fluoroquinolones and beta lactam/macrolide combos for those with comorbidities)
CAP Prevention
Vaccinations for at risk groups:
>those at or over 65 yo (PCV13 and PPSV23)
>Children under 5 receive PCV7 as routine vaccines
>those high risk from 6-64
What is the peak month for CAP
FEB
How likely is fever with acute bronchitis, flu and pneumonia?
Unlikely
Yes
Likely
How likely is cough with acute bronchitis, flu and pneumonia?
More than 5 days and mucopurulent
Common
Mucopurulent or rust colored
How likely are other symptoms with acute bronchitis, flu and pneumonia?
Uncommon
Myalgia, malaise
Chills, dyspnea
Typical cause of acute bronchitis, flu and pneumonia?
often viral
viral
often bacterial
Prevention of acute bronchitis, flu and pneumonia?
Hygiene
Vaccine/hygiene
Vaccine
Treatment of acute bronchitis, flu and pneumonia?
Symptomatic based
Antivirals/symptomatic
Antibiotics
Define asthma
A chronic inflammatory condition of the lungs that results in bronchoconstriction, excess mucus production, periodic symptoms of shortness of breath
Asthma prevalence
7.3% of population (1 in 13 Americans), 3,630 deaths per year in US, most common chronic disease of children (around 50 percent markedly improve or are symptom free as adults)
Describe child onset for asthma
More likely to be allergic based
Possible genetic predisposition to IgE mediated response to aeroallergens
Describe adult onset for asthma
More often non-allergic
Often negative family history and negative skin tests to common allergies
Possibly due to environmental exposure
Possible causes of asthma
Genetic factors (although no single genetic abnormality known causes asthma)
Environmental (hygiene, tobacco, sibling/daycare effect)
Asthma symptoms and triggers
Symptoms - coughing, wheezing, chest tightness, shortness of breath
Triggers - allergens, irritants, medicine, sulfites in foods and drinks, upper respiratory infections, physical activity, emotions
Anticholinergics target ____________
cGMP
Beta-agonists target ________
cAMP
Leukotrienes target ___________________
The leukotrienes that results from the lypoxygenase pathway
Leukotrienes are potent _________________
broncho-constrictors
Symptoms, short-acting beta agonist use and night time awakenings due to dyspnea with intermittent asthma
less than or equal to 2 days
less than or equal to 2 days
less than or equal to 2 days/month
Symptoms, short-acting beta agonist use and night time awakenings due to dyspnea with mild-persistent asthma
over 2 days a week
over 2 days a week
3-4 time a month
Symptoms, short-acting beta agonist use and night time awakenings due to dyspnea with moderate-persistent asthma
daily
daily
1-3 time weekly
Symptoms, short-acting beta agonist use and night time awakenings due to dyspnea with sever-persistent asthma
throughout day
several times per day
over 4 times a week
Objective asthma information can be obtained using these 3 methods
Peak flow meter (helps create asthma action plan), spirometry (lung volume, FEV1/FVC ratio, response to bronchodilation after albuterol administration) and lung sounds
Pharmaceutical options for Asthma
Rescue drugs:
Short acting beta adrenergic agonists (SABA)
Inhaled anticholinergics
Controller drugs:
Inhaled corticosteroids
Non-steroid controllers (mast cell stabilizers, leukotriene modifiers)
Therapy relievers or controllers:
Long-acting bronchodilators aka inhaled beta agonists (salmeterol, formoterol) - typically combined with inhaled corticosteroid
Additional therapy options include phosphodiesterase inhibitors, theophylline, allergy desensitization drugs
How to decide to “step-up” or “step-down” in asthma step treatment
step up if needed (first check adherence, environmental control and comorbid conditions)
Step down if possible (and asthma is well controlled for AT LEAST 3 months)
Step 6 for Asthma Therapy
High-dose ICS + LABA and oral corticosteroid
Consider omalizumab for patients with allergies
Step 5 for Asthma Therapy
High dose ICS + LABA
Consider omalizumab for those with allergies
Step 4 for Asthma Therapy
Medium dose ICS + LABA (LTRA, Theophylline or Zileuton would be good alternatives for LABA)
Step 3 for Asthma Therapy
Low dose ICS + LABA or Medium dose ICS
Step 2 Asthma Therapy
Low dose ICS (Cromolyn, LTRA, Nedocomil or Theophylline are fine alternatives)
Step 1 Asthma Therapy
SABA PRN
Risk factors for death from asthma
Hospitalizations (2 or more for asthma in past year, 3 or more ED visits for asthma in past year, hospitalization or ER visit for asthma in past month)
Using over 2 canisters of SABA in 1 month
Difficulty perceiving asthma symptoms or severity
Lack of asthma plan, sensitive to alternate medications
How to manage exercise-induced asthma
SABA (prevention in more than 80% of patients)
LABA, LTRA and cromolyn or nedocromil
Define COPD
A commonly preventable and somewhat treatable disease characterized by persistent airflow limitation and obstruction, usually progressive and associated with enhanced chronic inflammatory responses in the airways and lungs to noxious particles or gases.
Risk factors for COPD
smoking is number 1 risk factor.
Exposure to particles, gender and age, genes (antitrypsin-1-deficiency), and chronic asthma and reoccurring upper respiratory tract infections
Emphysema characteristics
“PINK PUFFER”
Alveolar problem, increase CO2 retention, minimal cyanosis, pursed-lip breathin, dyspnea, increased respiratory rate, hyperresonance on chest percussion, orthopneic, barrel chest, exertional dyspnea, prolonged expiratory time, speaks in short jerky sentences, anxious, use of accessory muscles to breath, thin
Chronic Bronchitis Characteristics
“BLUE BLOATERS”
Color dusky to cyanotic, recurrent cough with sputum production, hypoxia, hypercapnia, acidosis, edematous, increased respiratory rate, exertional dyspnea, increase incidence in heavy smokers, digital clubbing, cardiac enlargement, use of accessory muscles to breath
Goals of COPD treatment
Subjective - get patient to feel good since you can’t reverse disease
Objective: FEV1/FVC, mMRC, CAT; history of exacerbation or previous hospitalizations, lung sounds
Pharmacological principles and COPD
Medications may reduce or eliminate symptoms, increase exercise capacity, reduce exacerbation and improve quality of life (don’t really change lung volume though)
Current medications don’t slow or stop long term decline in lung function or prolong survival
Bronchodilation is primary approach
Once therapy added, it is rarely stopped
Low Risk, Less Symptoms Assessment Values of COPD
Spirometric Classification (GOLD 1-2)
Exacerbations per year (1 or less)
CAT (under 10)
mMRC (0-1)
Low risk, more symptoms Assessment Values of COPD
Spirometric Classification (GOLD 1-2)
Exacerbations per year (1 or less)
CAT (10 or more)
mMRC (2 or more)
High Risk, Less Symptoms Assessment Values of COPD
Spirometric Classification (GOLD 3-4)
Exacerbations per year (2 or more)
CAT (under 10)
mMRC (0-1)
High risk, more symptoms assessment values of COPD
Spirometric Classification (GOLD 3-4)
Exacerbations per year (2 or more)
CAT (10 or more)
mMRC (2 or more)
Describe GOLD stage 1 (mild)
FEV1 over 80
Describe GOLD stage 2 (moderate)
FEV1 between 50-80
Describe GOLD stage 3 (severe)
FEV1 between 30 and 50
What do you add at GOLD stage 2?
Regular treatment with one ore more long-acting bronchodilators
What do you add at GOLD stage 3?
Inhaled glucocorticosteroids if repeated exacerbations
What do you add at GOLD stage 4?
Long term oxygen if chronic respirator failure and consider surgery
What should be added for all stages of GOLD therapy
short-acting bronchodilator prn
When should antibiotics be used in COPD?
When patient presents with 3 cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence
As well as in those that require mechanical ventilation
Onset differences between asthma and COPD
Early in life/later in life
Etiology differences in asthma/COPD
immunologic stimuli, family history/smoking and other risk factors
Course differences between asthma and COPD
intermittent/chronic and progressive
Clinical features in asthma vs COPD
wheezing, chest tightness, dyspnea and cough/chronic cough/sputum, persistent or worsening dyspnea
Inflammatory mediator in asthma vs COPD
eosinophils/neutrophils
What guidelines are used for asthma? for COPD?
Asthma - National Asthma Education and Prevention Program (NAEPP)
COPD - GOLDs, American Thoracic Society (ATS) and European Respiratory Society (ERS)
Which groups tend to have higher incidence of asthma?
children, boys, adult women, Puerto Ricans, residents in the northeast corridor of the US, those living in poverty, and those exposed to certain chemicals
Severe viral respiratory infections during the first _____ years of life is a primary risk factor for asthma
3
List some drugs that are common triggers for asthma
NSAIDs, Aspirin, beta-adrenergics
A drop in ____ can be the first sign of an impending asthma exacerbation
PEF
As far as symptoms are concerned, what is a key difference between asthma and COPD?
COPD presents with a productive cough; asthma may present with chest tightness (both present with wheezing)
What is PEF?
Peak Expiatory flow (goal is at least 80 percent of personal best)
What is the reason for the caution label on first-generation antihistamine agents for asthmatics?
Anticholinergic properties may thicken mucus and decrease mucociliary clearance
Inhaled medications have _________ adverse effects compared with systemic medications
Fewer
What are some of the characteristic symptoms of aspirin sensitivity??
itchy or watery eyes, itchy rashes, rashes around mouth, nasal congestion, hives, worsening asthma, coughing, wheezing or anaphylaxis
Significant cross-sensitivity exists between aspirin and ______
NSAIDs
What are some common side effects associated with non-selective beta-agonists? What is the mechanism that causes these side effects?
arrhythmias, nervousness, palpitations
beta-agonists can also act on alpha receptors, constricting blood vessels and increasing blood pressure, leading to the adverse effects listed above.
Which vaccine should all patients with asthma (who are 6 months of age or older) receive yearly?
Influenza
What does FEV1 measure?
The amount of air expired in the first second as the subject forcefully exhales from a maximum inspiration
How does a patient determine PEF?
Twice daily, once in morning and once in early evening, 15-20 minutes after the use of a quick-relief inhaler
Anyone using a MDI should use a _______ to ensure optimal medication delivery to lungs
VHC - Valved holding chamber
The corneal epithelium is _______________, facilitating the passage of ___________ - soluble drugs.
Lipophilic, fat soluble
The corneal stroma is _______________, facilitating the passage of ___________ - soluble drugs.
Hydrophilic, water-soluble
Angle closure can be caused by any agent with __________________ or _________________ effects
antiocholinergic, dilating
Miotic means ____________
Mydriatic means ____________
closing, opening
The leading cause of blindness in the US is ______________________________
Macular Degeneration
What is the difference between viscosity of products and severity of dry eye disease?
More viscous products for more severe form of disease
For dry eye disease, what is the general recommendation for how often to use drops?
bid to start, with more sever cases qid
If multiple medications are used in the eye, how long should you wait between drops? What if a drop and ointment are to be used?
5 minutes
Use drops 10 minutes before ointment
This is a main counseling point for eye ointments
Blurred vision
Should contacts be worn with allergic conjunctivitis?
No
Nonpharmacologic therapy options for allergic conjunctivitis
Cold compresses, keeping doors and windows closed, checking the pollen count, using air filters, running air conditioners
What are the recommended pharmacologic treatment options for allergic conjunctivitis?
First-line is artificial tears prn; opthalmic antihistamine/mast cell stabilizer should be used if symptoms persist
What are the 4 OTC decongestants available for application to eye?
Phenylephrine, naphazoline, tetrahydrozoline, oxymetazoline
Ocular decongestants should not be used for more than ___________________ due to risk of ________________________________
72 hours, rebound congestion
Use of ocular decongestants in ___________________________ is contraindicated
angle-closure glaucoma
Name the 2 OTC ophthalmic antihistamines
pheniramine maleate and antazoline phosphate
Ophthalmic antihistamine/mast cell stabalzer
ketotifen fumerate
Ophthalmic antihistamines may cause __________________ due to their ____________________________ properties. Therefore they are contraindicated in people with _________________________
pupil dilation
anticholinergic properties
angle-closure glaucoma
___________ is the safest and most effective product for treatment of allergic conjunctivitis. Another effective alternative is ______________________
Ketotifen (bid), Naphazoline
Rebound congestion is less likely in which ocular decongestants/antihistamines?
Naphazoline and tetrahydrozoline, compared with phenylephrine and oxymetazoline
What is a hallmark symptom of corneal edema
halos or starbursts around lights
What is the purpose of hyperosmotic agents as ophthalmic products?
increase tonicity of tear film, promoting movement of fluid from cornea to more osmotic tear film
Minor eye irritation can be treated with _________________, a mild astringent.
Zinc sulfate
Generally, patients treating ophthalmic disorders should see a physician if symptoms persist after _________
72 hours
Currently, the only approved cerumen-softening agent is ________________________________
Carbamide peroxide 6.5% in anhydrous glycerin (approved for treatment in adults and children 12 and older)
How does carbamide peroxide work as an otic product?
When exposed to moisture, nacent oxygen released slowly and acts as weak antibacterial; the effervescence along with effects of urea on tissue helps to mechanically break down and loosen cerumen
How long can carbamide peroxide be used?
Generally bid up to 4 days since non-irritating
What is the main difference between administering otic products to children compared with adults?
If patient is under 3, pull ear back and down (as opposed to back and up)
_________________________________ is the only FDA approved ear-drying aid
isopropyl alcohol 95% in anhydrous glycerin 5%
50:50 mixture of ________________ and _____________ has bactericidal and antifungal properties
acetic acid 5%, isopropyl alcohol 95%
The majority of colds in children and adults are caused by _____________
rhinoviruses
Describe the clinical presentation of a cold
Sore throat first, followed by nasal symptoms which dominate 2-3 days later, with cough appearing (sometimes) on day 4 and 5
Rhinovirus cold symptoms persist for ___ to ___ days
7-14
Nonpharmacologic therapy recommendations for cold
increase fluid intake, adequate rest, nutritious diet, increased humidification and steamy showers (for children, upright positioning)
What are some exclusions for self-treatment for colds?
Fever over 101.5, chest pain or shortness of breath, AIDS, older more frail patients, infants under 9 months, hypersensitivity to recommended OTCs
List the direct, indirect and mixed decongestants and describe differences
Direct (act directly on adrenergic receptors): Phenylephrine, oxymetazoline and tetrahydrozoline
Indirect (displace norepinephrine from storage vesicles): ephedrine
Mixed: Pseudoephedrine
Systemic decongestants include ___________. How about short-acting (intranasal)? Long-acting (intranasal)?
pseudoephedrine, phenylephrine
naphazoline, phenylephrine
oxymetazoline
Adverse effects associated with decongestants include
cardiovascular and CNS stimulation
Therapy of ___ to ___ days is accepted to avoid rebound congestion
3-5
Decongestants are contraindicated in patients receiving _____ inhibitors
MAO (since MAO metabolizes decongestants)
_______-containing products should not be used in children with viral illnesses due to the risk of Reye’s syndrome
Aspirin
Decongestants may decrease _____________________ in new mothers
milk production (counsel to drink plenty of liquids)
FDA does not recommend non-prescription cold medications in children under ____
2
What patient factors should be considered when treating a cold?
Symptoms longer than 7-14 days or suspected chronic condition should not self-treat; those overly sensitive to adrenergic stimulation (diabetes, cardiovascular diseases, etc.) should not self-treat
____ and __________________ are popular complementary therapies for colds
Zinc, high-dose Vitamin C (doses of 4g/day are not recommended)
Describe the pathogenesis (4 phases) of allergic rhinitis
- sensitization on initial allergen exposure, stimulating b-lymphocyte mediated IgE production
- Early phase - occurring within minutes of subsequent allergen exposure; rapid release of mast cell mediators and production of other mediators
- Cellular recruitment - circulating leukocytes, especially eosinophils, are attracted to nasal mucosa and cause release of more mediators
- Late phase (2-4 hours after allergen exposure) - mucus hypersecretion, congestion
Systemic symptoms of allergic rhinitis
Fatigue, irritability, malaise and cognitive impairment
How do you differentiate between intermittent and persistent allergic rhinitis? Mild or moderate/severe?
symptoms 4 days or less vs more than 4 days per week
impairment of sleep or daily activities is how you distinguish if allergic rhinitis is moderate-severe
Nonpharmacologic recommendations for allergic rhinitis
Allergen avoidance, cat baths if you own a cat,
Pharmacologic Therapy for allergic rhinitis
Intranasal corticosteroids are most effective; oral antihistamines, mast cell stabilizers; patients should regularly use these products and should take them at least 1 week prior to when symptoms typically appear
What are the two INCSs that are approved for OTC use
Triamcinolone acetonide (Nascort) - adults and children over 2
Fluticasone propionate (Flonase) - adults and children over 4, 2 sprays per nostril/day and 1 spray per nostril/day, respectively
What is an important counseling point for when symptom relief should be seen when using INCSs?
Complete symptom control may not be seen for up to 1 week
What are the 2 major classes of antihistamines available for allergic rhinitis?
First generation (sedating, but come with anticholinergic effects) and second generation (non-sedating)
In first-generation antihistamine use, children are more likely to experience _____________ CNS effects while adults are more likely to experience ______________ CNS effects
excitatory, depressing
Fexofenadine should not be taken with any _______________
fruit juices
Sedating antihistamines are contraindicated in patients with
Narrow-angle glaucoma, lactating women and premature infants
Whats an important counseling point for sedating antihistamines?
Photosensitizing
What are the primary first-generation antihistamines? Second?
Diphenhyramine, Doxylamine, brompheniramine, clorpheniramine
Loratadine, cetirizine (most potent but has been known to cause sedation), fexofenadine
What is cromolyn sodium used for?
Mast cell stabilizer for treatment/prevention of allergic rhinitis (takes 3-7 days for initial efficacy and 2-4 weeks for max therapeutic benefits)
What is the first-gen of choice in pregnant women?
Chlorpheniramine
Antihistamines are contraindicated during __________
Lactation
For children under 12, what are the antihistamines of choice?
Loratadine, followed by fexofenadine and cetirizine (sedating antihistamines should be avoided in children)
What are the antihistamines/drugs of choice in older populations for allergic rhinitis?
Loratadine and cromolyn
How do you differentiate between an acute, sub-acute or chronic cough?
3 weeks
3-8 weeks
over 8 weeks
Drug of choice for non-productive coughs
Antitussives (codeine, dextromethorphan, diphenhydramine and chlophedianol [mild anesthetic with anticholinergic effects] hydrochloride)
Cautious hydration is recommended for patients with…
lower respiratory tract infections, heart failure, renal failure, etc.
The combination of dextromethorphan and MAOIs may cause _________________________
Serotonergic syndrome (should not be taken for at least 14 days after MAOI is discontinued)
________________ is the only FDA approved expectorent
Guaifenesin
What does the ACCP recommend regarding cough associated with a common cold?
First-generation antihistamine/decongestant combo; also suggests that the anti-inflammatory naproxen may reduce viral-associated cough
What does the ACCP recommend for cough associated with acute and chronic bronchitis as well as postinfectious subacute cough?
Codeine or dextromethorphan
Cough and cold medicines should not be used to treat infants under ____ years of age
2
What can be said about diphenhydramine in lactating mothers and the elderly?
Not appropriate (can be excreted in breast milk)
Dextromethrophan, diphenhydramine and chlophedianol should not be taken concurrently with _____
MAOIs
What shouldn’t be given to children under 1 due to a risk of botulism?
Honey
