Pulmonary Flashcards
which class of asthma meds are used for RESCUE ONLY
SABA
which 2 agents are SABAs
albuterol levalbuterol
which med is a ICS/SABA? how is it used?
budesonide/albuterol
reliever only
AEs of SABAs
tremor, shaky, lightheaded, palpitations
what are the 5 ICS
ciclesonide
fluticasone (propionate, furoate)
beclomethasone
mometasone
budesonide
2 major AE of ICS
oropharyngeal candidiasis, dysphonia
counsel for ICS to
rinse and spit with each us
which inhaler type should be shaken? not?
shake MDI
do not shake DPI
avoid DPI in
children <4 and milk protein allergy
3 LABAs? should they be used alone for asthma?
salmeterol, formoterol, vilanterol
DO NOT USE ALONE IN ASTHMA- BBW
BBW for LABA
asthma related death when used alone
4 ICS/LABA combos
budesonide/formoterol
fluticasone propionate/salmeterol
fluticasone furoate/vilanterol
mometasone/formoterol
which agent is a LAMA? when is it used
tiotropium
usually add on later
3 leukotriene modifiers
montelukast, zafirlukast, zileuton
AE for leukotriene modifiers
headache, psych changes
montelukast suicide BBW
asthma PO med dosed based on serum concentrations
theophylline
should OTC epinephrine be used for asthma
limit to short term use for unexpected situations, facilitate follow up
which 2 conditions are part of atopy and may contribute to asthma
eczema, allergic rhinitis
which meds can trigger asthma
ASA, NSAIDs, nonselective BB
4 main symptoms of asthma
wheezing, SOB, chest tightness, cough
signs of asthma
wheezing, dry cough, atopy signs, low O2 sat
how & when is asthma severity assessed
retrospective, after controlled for several months
mild, moderate, and severe asthma are controlled with which steps of therapy….
mild- step 1 or 2
mod- step 3 or 4
sev- step 5
how is asthma symptom control assessed? what do you ask?
daytime asthma sx >2x week?
nighttime waking?
reliever for sx >2x week?
activity limitations?
0= well controlled
1-2= partly controlled
3-4= uncontrolled
when assessing asthma symptom control do you always consider frequency of reliever use for symptoms? when would you not?
Do not as if use ICS/formoterol for reliever, do not include reliever for exercise
if asthma symptoms <3-5 days a week with normal/mild reduced lung function, start on which step of therapy?
step 1 or 2
is asthma symptoms most days, waking at night once a week or more, and low lung function, start on which step of therapy?
step 3
if daily asthma symptoms, waking at night once a week or more, low lung function, or a recent exacerbation, start on which step of therapy
step 4
what is started on step1-2 of asthma therapy
PRN only low dose ICS-formoterol
what is started on step 3 of asthma therapy
low dose maintenance ICS/formoterol
what is started on step 4 of asthma therapy
medium dose maintenance ICS/formoterol
what is preferred to use as the reliever for all steps of asthma therapy? alternate?
ICS/formoterol preferred
SABA alternate
2 main options if moving to step 5 of asthma therapy
high dose ICS/formoterol
add on a LAMA
after asthma therapy have been well controlled for 3 months, you can
maintain or step down therapy then reassess
if after a few months asthma is partly controlled or uncontrolled what do you do
check adherence and technique
step up 1 step
how to treat exercise induced bronchospasm in asthma
PRN SABA used once before exercise
patients managing an acute asthma exacerbation at home should
follow asthma action plan
increase reliever or controller
presentations of mild and moderate asthma exacerbation
pulse 100-120 bpm
O2 sat 90-95%
talk in phrases
prefers to sit
not agitated
no accessory muscle use
what should be assessed for asthma exacerbations
severity of sx (dyspnea), vitals, ability to complete sentences, consciousness, O2 sat, no response to initial therapy
(primary care) treatment for mild asthma exacerbation include
SABA 4-10 puffs Q20 min for 1 hour
prednisone
oxygen
O2 sat target for asthma exacerbation
93-95%
what is done for mild/mod asthma exacerbation discharge
reliever continue PRN
start or step up controller/ICS
steroid continue x5-7 days
(ED) treatment for moderate asthma exacerbation include
SABA
controlled O2
prednisone 50 mg
presentations of severe asthma exacerbation
RR>30
accessory muscle use
pulse >120 bpm
O2 sat <90
what is initiated for severe asthma exacerbation
SABA
ipratropium bromide
controlled O2
prednisone
which 2 agents may be considered for use in severe asthma exacerbation
IV magnesium
high dose ICS
main 2 environmental causes of COPD
smoking, occupational exposure
3 risk factors for COPD
smoker/exsmoker, >age 40, men
COPD is diagnosed with spirometry showing an FEV1/FVC of
<0.7
symptoms of COPD
dyspnea, chest tightness, wheezing, fatigue, activity limitation cause, +/- sputum production
which 3 classes are bronchodilators used for COPD
beta 2 agonists
muscarinic antagonists
theophylline
2 SABAs used for COPD
albuterol, levalbuterol
4 LABAs used for COPD
salmeterol, formoterol, arformoterol, olodaterol
which 2 LABAs for COPD are nebulizer only
formoterol, arformoterol
AEs of beta 2 agonists
tachycardia, tremor, tachyphylaxis
SAMA used for COPD
ipratropium bromide
LAMAs used for COPD (4)
tiotropium, aclidinium, umeclidinium, revefenacin
AEs of LAMAs for COPD
dry mouth, cough, blurred vision, metallic taste (tio)
what is a SABA/SAMA combo medication? how is it available
albuterol ipratropium
combivent respimat – SMI
DuoNeb – nebulizer
DuoNeb is contraindicated in
soybean and peanut allergy
4 LAMA/LABA combo agents
tiotropium/olodaterol (stiolto)
umeclidinium/vilanterol (anoro)
glycopyrrolate/formoterol (bevespi)
aclidinium/formoterol (duaklir pressair)
4 ICS/LABA combos that may be used in COPD
fluticasone furoate/vilanterol (breo)
budesonide/formoterol (symbicort)
mometasone/formoterol (dulera)
fluticasone propionate/salmeterol (advair, wixela, airduo)
which 2 agents are triple therapy (ICS/LAMA/LABA) used for COPD
fluticasone furoate/umeclidinium/vilanterol (trelegy)
budesonide/glycopyrrolate/formoterol (breztri)
what is a PDE4 inhibitor that may be used PO in COPD
roflumilast (daliresp)
AEs of roflumilast
nausea, diarrhea, weight loss, sleep disturbances, HA, worsen depression
COPD gold 1 mild FEV1 is
≥80
COPD gold 2 (moderate) FEV1 is
50-79
COPD gold 3 (severe) FEV1
30-49
COPD gold 4 (very severe) FEV1 is
<30
regardless of COPD symptom scores, having ≥2 mod exacerbations OR ≥1 leading to hospitalization puts you in COPD class ___
E
in COPD, if has 0 or 1 mod exacerbation (no hospitalization), and a mMRC of 0-1 OR CAT<10, they are class __
A
in COPD, if has 0 or 1 mod exacerbation (no hospitalization), and a mMRC ≥2 OR CAT ≥10, they are class ___
B
initial therapy for COPD in class A is
a bronchodilator
LAMA or LABA preferred over SAMA or SABA
initial therapy in COPD for class B is
LABA + LAMA combo better than mono
initial therapy in COPD for class E is
LABA + LAMA
AND ICS IF BLOOD EOS >300
when are ICS favored in COPD
blood eos >300
concomitant asthma
history of hospitalization for exacerbation
3 or more mod exacer/yr
in addition to maintenance therapy, ALL COPD PATIENTS should be prescribed
SAMA, SABA, or a combo (preferred)
if at COPD follow-up a patient is still having PREDOMINANT DYSPNEA and is on a LABA or LAMA, what do you do next?
switch to LABA/LAMA combo
if at COPD follow-up a patient is still having PREDOMINANT DYSPNEA and is on a LABA/LAMA combo, what do you do next?
switch inhaler device or molecules
implement nonpharm
check for other dyspnea causes
if at COPD follow-up a patient is still having PREDOMINANT EXACERBATIONS and is on a LABA or LAMA, what do you do next if blood eos <300 or >300?
<300 –> switch to LAMA/LABA combo
>300 –> switch to LAMA/LABA/ICS combo
if at COPD follow-up a patient is still having PREDOMINANT EXACERBATIONS and is on a LABA/LAMA combo with blood eos >100 what do you do?
switch to LAMA/LABA/ICS combo
if at COPD follow-up a patient is still having PREDOMINANT EXACERBATIONS and is on a LABA/LAMA combo with blood eos <100 OR is on a LAMA/LABA/ICS, what do you do?
-if FEV1<50 or chronic bronchitis?
-if former smoker?
FEV1<50 or chronic bronchitis- roflumilast
former smoker- azithromycin
if at COPD follow up patients are having both dyspnea and exacerbation symptoms, which treatment pathway do you follow
exacerbation pathway
what do you do at COPD follow up with a patient on a ICS/LABA if they have coexisting asthma
continue therapy
what do you do at COPD follow up with a patient on a ICS/LABA if they do not have asthma but are controlled
continue
what do you do at COPD follow up with a patient on a ICS/LABA if they do not have asthma but have major symptoms
switch to LAMA/LABA
what do you do at COPD follow up with a patient on a ICS/LABA if they do not have asthma and are having exacerbations with blood eos >100 or <100
> 100 – switch to LAMA/LABA/ICS
<100 – switch to LAMA/LABA
5 main nonpharm treatments for COPD
smoking cessation
vaccines
pulm rehab (group B & E)
oxygen therapy
noninvasive ventilation
3 triggers for COPD exacerbation ? what do they cause?
bacteria, viruses, pollutants – inflammation of airways
characteristics of mild COPD exacerbation include
no resp failure, mild tachypnea
HR <95, RR<25, O2 >92
characteristics of moderate COPD exacerbation include
acute non life threatening resp failure
significant tachypnea
use of accessory muscles
PaCO2 50-60
HR >95, RR>24, O2 sat <92
characteristics of severe COPD exacerbation
acute life threatening resp failure
significant tachycardia
use of accessory muscles
acute mental status change
PaCO2 >60
acidosis
what are the 4 main therapies initiated for an acute COPD exacerbation
oxygen
SABA/SAMA
LAMA/LABA
steroids
what is target O2 sat with oxygen therapy for COPD exacerbation
88-92%
what short acting bronchodilators can be used for acute COPD exacerbation
albuterol
levalbuterol
ipratropium
ipratropium/albuterol combo
when are long acting bronchodilators used for acute COPD exacerbation
when stable and can tolerate inhalers
how long are steroids used for COPD exacerbation?
what is used for mild/mod? severe?
5 DAYS TOTAL
mild/mod- prednisone 40 mg
sev- methylprednisolone 60 mg IV Q8-12H
when are antibiotics used for COPD exacerbation
> sputum purulence + >dyspnea or >sputum volume
which abx should NOT be used for COPD exacerbation
erythromycin, Bactrim, amoxicillin, 1st gen ceph
which abx are used and how long for COPD exacerbation if uncomplicated, <4 exac/yr, & no comorbidities
macrolide, 2nd/3rd gen cep, doxycyline
x5 days
which abx are used and how long for COPD exacerbation if complicated, >65 y/o, >4 exac/yr, or comorbidities
amox/clav, fluoroquinolone x 5 days
which abx are used and how long for COPD exacerbation if high risk for MDR pathogens
levofloxacin, cefepime, ceftazidime x5-7 days
classification of allergies if symptoms <4 days per week or <4 weeks per year that do not interfere with life
mild intermittent
classification of allergies if symptoms <4 days per week or <4 weeks per year that DO interfere with life
mod to sev intermittent
classification of allergies if symptoms >4 days per week or >4 weeks per year that do not interfere with life
mild persistent
classification of allergies if symptoms >4 days per week or >4 weeks per year that DO interfere with life
mod to sev persistent
2 nonpharm options for allergies
nasal saline
adhesive nasal strips
IN steroids work for which allergic symptoms
ALL
AEs of IN steroids
HA, dryness, burning, stinging, blood tinged secretions
oral antihistamines work for which allergy symptoms
all except congestion
IN antihistamines work which allergy symptoms
all except ocular
AEs of IN antihistamines
bitter taste, epistaxis, HA
topical decongestants should be used how long
3 days or less
ocular antihistamines work for which symptoms of allergies
ocular only
IN cromolyn works for which allergy symptoms
all except ocular
IN ipratropium helps which allergy symptoms
rhinorrhea
allergy choice if primarily nasal congestion
INS or PO decongest
allergy choice if primarily sneezing, nasal itch, rhinorrhea
OAH, IN antihistamine
allergy choice if primarily mild sx
OAH
allergy choice if primarily mod/sev symptoms
INS, IN antihistamine, combo
if INS not helping enough what can you add
IN antihistamine or oxymetazoline
if OAH not helping enough what can you add
PO decongestant
if IN antihistamine not working enough what can you add
IN steroid
