Pharm - Asthma Flashcards
Given a patient with asthma presenting symptoms, physical exam information, PEF or FEV1, and blood gases, classify severity as moderate.
- talking in phrases/sentences; alert/agitated; may or may not use accessory muscles
- PFR > 200 L/m or 50-75% best or predicted
- O2 > 92%
- HR < 120
- RR < 30
Given a patient with asthma presenting symptoms, physical exam information, PEF or FEV1, and blood gases, classify severity as severe
- using words or unable to complete sentence; agitated; usu use accessory muscles
- PFR < 200 L/m or 33-50% best/predicted
- O2 < 92%
- HR > 120
- RR > 30
Given a patient with asthma presenting symptoms, physical exam information, PEF or FEV1, and blood gases, classify severity as life threatening
- unable to talk; confused, drowsy or coma; usu use accessory muscles
- PFR < 200 L/m or < 33% best/predicted or unable to do it
- O2 < 90%; cyanosis; nl to high CO2, acidosis
- HR > 120 or bradycardia / silent chest
- RR > 30 unless resp. failure
major risk factors for a fatal asthma attack
i. Recent history of poorly controlled asthma
ii. Prior history of near-fatal asthma
(~70% of patients report prior history of intubation or cardiopulmonary resuscitation)
minor risk factors for a fatal asthma attack
i. Allergic asthma
ii. Food allergies
iii. Aspirin/NSAID-induced asthma
iv. Sports/exercise→MC in basketball and track
v. Illicit drugs→cocaine/heroin
vi. Smoking
vii. Respiratory viruses→picornavirus/adenovirus
viii. Menstruation
ix. Other: long duration asthma, non-adherence, comorbid illnesses, delay in getting care
goals of treatment for an acute asthma exacerbation
a. Rapid reversal of airflow limitation: airflow limitation is most rapidly alleviated by combining repeated inhaled bronchodilators and early systemic glucocorticoids
b. Correct severe hypercapnia/hypoxemia
what is the treatment of choice for an acute asthma exacerbation
SABAs are 1st line for acute asthma exacerbation
nebulized albuterol dose
- 2.5 - 5 mg by jet nebulization q 20min. x 3 doses
- then 2.5-10 mg q 1-4hrs PRN
MDI albuterol dose
4-8 puffs q 20 mins for 1st hour→used with spacer
continuous nebulization abuterol dose
10-15mg over 1 hour
place in therapy of ipratropium in an acute asthma exacerbation
In severe exacerbations:
- RR>30
- accessory muscles use
- HR>120
- O2<92%
- PFR<200 L/min
dose of nebulized delivery of ipratropium for an acute asthma exacerbation
- 500mcg Q 20 mins x3 doses
- Then PRN
dose of MDI delivery of ipratropium for an acute asthma exacerbation
-4-8 inhalations Q 20 mins PRN for up to 3 hours
role in therapy of systemic glucocorticoids
Essential for exacerbations refractory to intensive bronchodilator therapy because persistent airflow obstruction is likely due to airway inflammation and intraluminal mucus plugging
Identify the patients who are candidates for systemic glucocorticoids
a. Severe exacerbation with PEF ≤50% of baseline
b. Moderate exacerbation with PEF >50% but <70% of baseline
c. Exacerbation despite daily/alternate day oral glucocorticoid therapy→need additional glucocorticoids above baseline dose
time to effect of systemic glucocorticoids
Onset of action usually not clinically apparent until about 6 hours after administration
IV dose of methylprednisolone
a. 40-60mg q 12-24 hours if admitted but not in ICU
b. 60-80mg q 6-12 hours if admitted to ICU
Identify the role of magnesium sulfate in the treatment of acute asthma
For patients who have life-threatening exacerbation or whose exacerbations remains severe (PEF <40%) after 1 hour of intensive conventional therapy
dose of magnesium sulfate in treatment of acute asthma
2g infused over 20 minutes
Identify the discharge medications a patient should have after treatment for an acute asthma attack
a. Oral glucocorticoids
b. Intramuscular glucocorticoids
c. Inhaled glucocorticoids
State the asthma education areas that should be covered before discharge
Medications, PEF device, asthma action plan
components of an asthma action plan
a. Agree on treatment goals
b. Teach patient how to use asthma action plan to take daily actions to control asthma, adjust medications in response to worsening asthma and seek medical care as needed
c. Encourage adherence to asthma action plan
i. Choose treatment that achieves outcomes and addresses preferences important to patient/family
ii. Review at each visit: any successes in achieving control, any concerns about treatment, any difficulties following the plan and any possible actions to improve adherence
iii. Provide encouragement/praise, which builds patient confidence. Encourage family involvement to provide support
the recommended dosage regimen for oral systemic glucocorticoids
40-60mg daily in 1-2 doses x 5-10 days
Given a patient with an asthma exacerbation select the most appropriate treatment on an outpatient basis
a. SABA should be self-administered when onset of exacerbation is recognized:
i. 2-8 puffs from MDI with spacer Q20 minutes for 1st hour
ii. Nebulized albuterol 2.5mg Q20 minutes for 1st hour if needed
iii. Then: if feels improvement, repeat peak flow measurement→subsequent SABA dose can be used if needed, or contact clinician
Identify the risks associated with over the counter inhaled epinephrine products
a. Chest pain, N/V, HTN, tachycardia, hemoptysis, defective atomizer devices
b. Epi is NOT a β-2 adrenergic receptor selective so has greater risk of β-1 and αadrenergic type ADEs, especially when used in excessive doses
