Pulm Flashcards
What should you not forget when determining DDx for a kid with a pulmonary issue?
Not all asthmatics wheeze, and not all wheezing is asthma
DDx: Asthma Acute bronchitis Pertussis Foreign Body Croup Viral URI
Why should a CXR be considered if you think a patient has asthma?
It’s helpful to r/o PNA, pneumothorax or FB
When is spirometry not recommended?
Kids <5 yo
During acute exacerbations of asthma
What is the standard treatment for acute asthma exacerbations?
SVN albuterol +/- ipratorpium
Different concentrations of albuterol available
Dosing of albuterol is dependent on…
Patient’s age and weight
Recommended dose of inhaled albuterol during acute bronchospasm/asthma exacerbation
0.15-0.3 mg/kg
If kid weighs 16.8kg —> 2.52 mg
Office carries Albuterol 0.083% (2.5 mg/3ml) —> give the kid 1 vial nebulized, may repeat every 20-30 min prn up to 3 doses
You give a kid with acute bronchospasm an SVN albuterol treatment and he is still wheezing. What do you do?
Repeat SVN albuterol 20-30 min later
What is the duration of action for albuterol?
4 hours
What class of drug is albuterol?
Short-acting beta agonist
Side effects of albuterol?
Tachycardia
Tremor
Nervousness
Dizziness
Besides the neb treatment of albuterol, what else might you give to a kid coming in for an acute asthma exacerbation?
Oral glucocorticoid
• Prednisolone 15mg/5ml qd x 5 days
• Prednisone 5 mg/5ml qd x 5 days
• (Dexamethasone is alternative)
Side effects of oral glucocorticoids
Anxiety
Agitation
Insomnia
Increased appetite
What is the dosing of albuterol MDI for bronchospasm?
1-2 puffs q4-6 hours prn for kids ≥4 years
What can you indicate on the prescription for little Johnny’s albuterol inhaler to make it easier for him to take?
“With spacer”
When should you recommend f/u for a kid with an acute asthma exacerbation?
In 2-3 days
Go to the ER if worsening Sx or no relief with albuterol
What can you give a kid whose asthma is not well controlled on albuterol alone (Mild Persistent asthma)?
Montelukast (singulair)
Fluticasone HFA (Flovent)
What are the criteria for intermittent asthma?
Sx ≤ 2 days/week
No nighttime awakenings
SABA use ≤2 days/week
No interference with normal activity
≤1 exacerbation/year
What are the classification criteria for mild persistent asthma?
Sx >2 days/week but not daily
Nighttime awakenings 1-2x/month
SABA use >2 days/week but not daily
Minor limitation of normal activity
≥2 exacerbations in six months requiring oral systemic glucocorticoids or ≥4 wheezing episodes/year lasting >1 day and risk factors
What are the classification criteria for moderate persistent asthma
Daily Sx
Nighttime awakenings 3-4x/month
Daily SABA use
Some limitation of normal activity
≥2 exacerbations in six months requiring oral systemic glucocorticoids or ≥4 wheezing episodes/year lasting >1 day and risk factors
What are the classification criteria for severe persistent asthma?
Sx throughout the day
Nighttime awakenings >1x/week
SABA use several times/day
Extremely limited activity
≥2 exacerbations in six months requiring oral systemic glucocorticoids or ≥4 wheezing episodes/year lasting >1 day and risk factors
What is step 1 for asthma treatment?
SABA prn
What is step 2 for asthma treatment in kids 0-4 years?
SABA prn
+
Low dose ICS or cromolyn or monolukast
What is step 3 for asthma treatment in kids 0-4 years?
SABA prn
+
Medium dose ICS
What is step 4 for asthma treatment in kids 0-4 years?
SABA prn
+
Med dose ICS
+
either LABA or montelukast
What is step 5 for asthma treatment in kids 0-4 years?
SABA prn
+
High dose ICS
+
Either LABA or montelukast
What is step 6 for asthma treatment in kids 0-4 years?
SABA prn
+
High dose ICS
+
Either LABA or montelukast
+
oral systemic steroids
What should be included with each step up in asthma treatment?
Patient education and environmental control
When can you consider stepping down asthma treatment
Asthma well controlled at least 3 months
Will ICS stunt little Johnny’s growth?
NOPE
Indications for Montelukast (singulair)
Asthma
Allergic rhinitis
Exercise induced bronchospasm
Urticaria (off label)
SE of montelukast
URIs
HA
Abdominal pain
MOOD CHANGES
What is the dosing recommendation for montelukast?
1-6yo = 4mg qd
6-15yo = 5mg qd
> 15yo = 10mg qd
When might you consider immunotherapy for a kid with asthma?
Once their symptoms are under control. No age limit.
When can you consider Omalizumab (Xolair) for a kid with asthma?
Not until 6 years old
What class of med is Advair?
Salmeterol/Fluticasone combo
LABA + ICS
What class of med is Tiotropium?
Long-acting anticholinergic (LAMA)
How long does it typically take for albuterol to take effect?
20 min
SE for tiotropium (Spiriva)
IT’S ANTICHOLINERGIC
HA Dry mouth Cough Nausea Blurred vision Dizziness
Benefit of Salmetrol/Fluticasone combo?
Lasts up to 12 hours (LABA + ICS)
SE of LABA + ICS combo
Same as for SABA plus THRUSH and HOARSENESS due to added ICS
How should you treat an acute COPD exacerbation?
SVN with albuterol/ipratropium
Recheck vitals and PE after tx
After you give your COPD patient some albuterol/ipratropium for his acute exacerbation, what should you consider next?
Intensification of bronchodilator therapy (SABA +/- SAMA)
Short course glucocorticoids
Abx (Macrolide or Fluoroquinolone) - reduces short term mortality by 77%
Follow up instructions for your dude with an acute COPD exacerbation
F/u in 2-3 days if not improving
Recommended ER if worsening dyspnea, CP, fever
F/u in 2 weeks for PFTs and BP check (PFTs not accurate during acute exacerbation)
STOP SMOKING
Patient staging (A-D) and suggested treatment of COPD is based on…
Assessment of symptoms and risk of exacerbation
SABA should be available for patients in category B-D for sx control PRN
