Pulmonary Flashcards
immediate hypersensitivity
exposed to allergen/trigger –> IgE, T helpers, mast cells, histamine
asthma: in the past 4 weeks has the patient had:
day time symptoms >2x/week
any night waking due to asthma
reliever needed >2x/week
any activity limitation due to asthma
3 types of asthma treatments
1) relievers/bronchodilators
2) bronchidilators (anticholinergic)
3) anti-inflammatories – ICS
albuterol sulfate
SABA = proair HFA, ventolin hfa, proventil hfa, nebulized
levalbuterol = xopenez
binds to beta2 receptors to cause fast=acting bronchodilation
onset <5 minutes, duration 4-6 hours, 2 puffs every 4-6 hours
SABA
ADRs of SABA
tachycardia, tremor, hypokalemia
salmeterol, formoterol, vianterol
LABA
long term bronchodilation that opens airway
LABA
can LABA be used alone
no
ABA is either __ or __
BID or QD
LABA is more
costly
inhaled versions of sympathomimetics are more ___
effective
ADRs of sympathomimetics
nausea, tachycardia, muscle tremors, cardiac and respiratory compromise
selective direct-acting stimulant of beta-2 receptors, causing smooth muscle to relax
terbutaline
terbutaline can also be used
to stop contractions in OB
toxicity of terbutaline
acidosis, rhabdo, ARF, SVT, a fib
IV terbutaline can cause
hypokalemia
ipatropium bromide
SAAC - atrovent, combivent, duoneb
blocks acetylcholine, relaxes + opens airway
SAAC/SAMA
PRN or QID
onset 15-20 min, duration 4-6 hours
ADR = dry mouth, nausea, metallic taste
SAAC/SAMA
tiotropium, glycopyrrolate, umeclidinium
LAMA/LAAC
blocks acetycholine longer
LAMA/LAAC
ADRS = dry mouth, constipation, urinary retention, tachycardia, blurred vision
LAMA/LAAC
fluticasone propionate, budesonide, beclometahsone, mometasone
ICS
rinse month after – to reduce thrush risk
ICS
ADRs = hoarseness, sore throat, thrush
treat with lowest dose possible
ICS
montelukast/singulair
leukotriene receptor antagonist
QHs, ages 12mo +, few DDIs
block action of leukotrines (antiinflam)
mild-severe asthma, goal for control + exacerbation reduction
almost equal to ICS
ADR= headache, N/V/D/ abdominal pain, flu-like
leukotriene receptor antagonists
sublingual immunotherapy
grass = grazax, odactra
ragweed = ragwitek
build up tolerance!
antibody for IgE
omalizumab (reduces response)
antibody for IL-5
mepolizumab (death of eosinophils)
antibody for IL-4
dupilumab (reduces inflammation)
moderate to severe asthma, SC
ADRS = injection site reaction, black box warning anaphylaxis, expensive
monoclonal antibodies
rarely used, mostly in hospital for severe refractory asthma
- bronchodilator, inibits phosphodiesterase, release of epi, relaxes, stimulates
narrow therapeautic index, seizures/arrhythmias LOTS of DDIs, CYP1A2, 2E1, 3A4 (smoking increases elimination, prolonged w/ CHF and hepatic disease)
theophylline/methylxanthine
children may need
delivery devices, leukotrine modifiers, pulmicort nebs
tx of asthma exacerbations
home – increased dosing of inhaler, may require oral steroids
er – controlled oxygen for >90%, nebulized SABA w/ SAMA
oral or IV steroids
– not used for exacerbations, rescue, or monotherapy in asthma
salmeterol
risk for anaphylaxis with
omalizumab
COPD treatments
SABA PRN
LABA for moderate-severe B-D w/ persistent symptoms
ICS for severe to very severe
ICS/LABA improves but increaed pneumonia risk
SAMA first line for
periodic COPD symptoms, PRN, maybe with SABA
LAMA/LAAC first line for
moderate-severe COPD w/ persistent symptoms
phosphodiesterase IV inhibitors
roflumilast (COPD only)
severe or very severe COPD uncontrolled
adjunct therapy
ADRs = weight loss, neuropsychiatric effects, bad in underweight, 3A4, 1A2
tiotropium vs LABA
tiotropium increased time to 1st exacerbation – dries up secretions
first line for COPD
smoking cessation, vaccines, O2 <88%
3 cardinal symptoms of COPD
increased dyspnea
increased sputum purulence
increased sputum volume
all 3 = severe
Risk for p aeruginosa in COPD exacerbation
- recent hospitalization
- chronic steroid use
- resident of nursing home
- > 4 courses of abx
- known pseudomonas infection in past
COPD exacerbation treatments –
SABA, steroids, O2
Abx recommended for COPD exacerbation treatment if
2/3 cardinal symtpoms + one includes increased sputum purulence
or 3/3
like bactrim, augmentin, doxy, clarithro, azithro
if at risk for p aeruginosa COPD abx
levofloxicin, zosyn, cefepime
if complicated COPD abx
augmentin, levo, moxi
if uncomplicated COPD abx
doxy, azithro, cefdinir, bactrim
cortisone
hydrocortisone
prednisone
methylprednisolone
dexamethasone
glucocorticoids
fludricortisone
mineralocorticoids
intermediate acting steroids
prednisone 5
methylprednisolone 4
long acting steroids
dexamethasone .75
corticosteroid dosing
equal to amount secreted by adrenal cortex
(physiologic)
or pharmacologic (supraphysiologic)
short term, high dose steroid ADRs
hyperglycemia
leukocytosis
GI bleeding (PUD)
insomnia
sodium and water retention
psychaitric status changes
increased appetite
long-term steroid ADRs
amenorrhea
cataracts
diabetes
osteoporosis
immunosuppression
HPA axis suppresion
HTN
myopathy
hypokalemia
acne
Cushing’s
main one to start young
leukotriene receptor antagonists
cushings syndrome is
hyperadrenocorticosism
from - primary defect
or excessive secretion of ACTH (pituitary adenoma), ectopic ACTH secreting tumor
or use of steroids with high dose + long term use
Dx w/ dexamethasone challenge (cushings = high levels of ACTH in morning blood draw)
moon face
central fat obesity
striae
buffalo hump
bruising
psychiatric changes
HTN
osteoporosis
glucose intolerance
amenorrhea
hirsutism
cushing’s
primary adrenal insufficiency
addison’s disease
adrenal gland not producing hormones from soemthing suppressing it (long-term exogenous steroid administration >14 days)
secondary adrenal insufficiency
hypotenison
hypoglycemia
N/V/D
chronic fatigue
loss of appetite
Addison’s
most common cause of — is chronic use of exogenous glucocorticoids + abrupt withdrawal w/
weakness
weight loss
GI symptoms
craving salt
HA
memory loss
depression
psotural dizziness
vomiting
fever
HOTN
shock
Addisonian crisis
hydrocortisone is TOC
tapering in addisons
cortisol 10-30mg - measure ACTH or AM serum cortisol
if normal/>20, daily steroid is unnecessary
if cortisol <3, continue therapy
courses of steroids >– weeks pose risk for HPA-axis suppression
2 weeks
Use shorter acting forumlations to prevent steroid withdrawal like
short - hydrocortisone
intermediate - prednisone/methylprednisone
long - dexamethasone
give in morning
limut duration
TAPER
anorexia
n/v
weight loss
lethargy
headache
fever
joint/muscle pain
postural HOTN
rapid reduction in corticosteroid levels
burst therapy
asthma/copd exacerbations
short term therapy x 5-7 days
no taper if <14 days
short term taper
taper over 2 weeks
60 x 3, 40 x 3, 20 x 3 off
long term taper
tapered over months
60 mg x 1-2wk
50 mg x 1-2 weeks
etc
long term ADR steroids
HTN
hypokalemia
hyperglycemia
osteoporosis
hidden infections
short term ADR steroids
GI, insomnia, excitability
ADR steroids
EKG changes
Edema
cushings
monitor with steroids –
glucose, WBC, short term side effects
take with food
don’t stop suddenly
drug side effects
timing
missed
use steroids cautiously with
PUD
HD, HTN, HF
infectious
psychoses
DM
osteoporosis
glaucoma
with trauma/surgery
10x dosage increase 48-72 hours
minor stress
2x dosage increase 24-48hrs
pregnant women can use
albuterol and budesonide
How do you calculate the percentage of pulm volume?
x/y = percentage
50-70 = yellow
<50 = red
green
> 80%
yellow
50-80%
SABA
red
<50%
SABA
go to ED
