Pulmonary Flashcards
Asthma Background
- _______ disease of the lungs
- Characterized by ______ episodes of acute bronchoconstriction
- Secondary to noxious ____ and ____ -reactive pulmonary airways
- Severity/progression _____ among patients
- Poorly controlled and/or untreated leads to permanent _____ damage and remodeling which can progress to?
- Inflammatory
- reversible
- stimuli, hyper-reactive
- variable
- structural -> COPD
Patho of Asthma
Medications Used to Treat Asthma
- ________ Agents (3)
- ________ Agents (2)
- (1)
- Bronchodilating
- Sympathomimetic Agents (Beta 2 Agonists)
- Methylxanthines (Theophylline)
- Antimuscarinic Agents
- Anti-inflammatory
- Corticosteroids
- Leukotrine Pathway Inhibitors
- IgE Monoclonal Antibody
B-2 Agonists MOA
Bind to B-2 receptors (_____ selective, may also bind to __ receptors) on smooth muscle in the ____ and activates adenylyl cyclase (AC) to yield ____ (intracellular mediator) ultimately ______ bonchial and trachial smooth muscles
moderately, B1, lung, cAMP, relaxing
cAMP -> promotes bronchodilation
+Sympathomimetic Agents
- Routinely admistered via _____
- Provides maximum concentrations to the ____
- Minimizes ______ absorption/toxicity
-
Short-acting B-2 agonists used for ______ therapy
- Indicated for m___, i______ asthma
- Long-acting B-2 agonists (LABAs) used for ______ therapy
- inhalation
- lungs
- systemic
-
rescue
- mild, intermittent
- maintenance
+Short Acting B-2 Agonists
(2)
Albuterol (Proair, Ventolin)
Levalbuteral (Xopenex)
Levalbuterol more selective than albuterol
+Long Acting B-2 Agonists (LABAs)
(4)
Salmeterol/fluticasone (Advair)
Formoterol/budesonide (Symbicort)
Vilanterol/fluticasone (Breo Ellipta)
Olodaterol/tiotropium (Stiolto Respimat)
The long acting B2 differs on which steroid combined with and how long they act
+Albuterol, Levalbuterol
- Maximum bronchodilation achieved ___ minutes after inhalation
- Duration of action ~__ hrs (Dosed q__-__ hrs prn)
- _____ is a purer form (____ selective for B-2, potential for less _______, sometimes more ____ for the pt)
- For those who cannot use an inhaler?
- _____ also available in an oral tablet
- Associated with ____ SE and no clinical advantage
- 15
- ~4 (Q4-6 prn)
- Levalbuterol (more, tachycardia, expensive)
- Nebulized
- Albuterol
- increased
+Salmeterol, Formoterol
- ______ duration of action (~__ hrs) - ____ daily dosing
- Always used in ______ with a ________
- Long, ~12, twice
- combination, corticosteroid
Antimuscarinic Agents
MOA
Works by blocking ___ receptors on ______ smooth muscle released from the _____ nerve pathways secondary to a ______ stimuli (_____ reactivity)
Blocks Ach, airway, vagal, noxious, hyper
Some ppl have excessive Ach
+Antimuscarinic Agents
(3)
Ipatropium bromide (Atrovent) - Short acting
Tiotropium (Spiriva) - Long acting
Umeclidinium (Incruse Ellipta) - Long acting
+Ipatropium (Atrovent) PK
- ____ acting
- Dose: ____ times a day
- Potent _____ analog (anti_____)
- _____ systemic absorption (Does not enter ____)
- Given via ______ route for?
- Enhanced bronchodilation when given with _____ (____)*
- Indication for COPD:
- Indication for Asthma:
- Muscarinic involvement is both (2)
- Short
- Multiple
- Atropine (anticholinergic)
- Minimal, X CNS
- Inhalation - Acute episodes in asthma
-
Albuterol (Combivent)
- maintenance therapy
- acute management in asthma (ER) or in pts intolerant to beta-agonists
- stimuli and patient dependent
+Tiotropium (Spiriva)
-
_____ acting
- Dose frequency
- Route, what form does it come in?
- Indication
-
Long
- Once daily
- Inhalation, powder
- Maintenance therapy for COPD
+Umeclidinium (Incruse Ellipta)
-
____ acting
- Dose frequency
- Route, what form does it come in?
-
Long
- Once daily
- Powder for inhalation
+Antiflammatory Agents Used to Treat Asthma
(2)
Corticosteroids
Leukotriene Pathway Inibitors
+Corticosteroids
MOA
- Inhibit production of _______
- Reduces _____ reactivity
- NOT a ________
- cytokines
- hyper
- NOT a bronchodilator
+Corticosteroids
Routes
Inhalation
Oral
+Corticosteroids Indications
When given via Inhalation
When given via Oral
Maintenance therapy in moderate to severe asthma
Severe, acute episodes AND refractory disease (many SE when given orally eg. prednisone)
+Corticosteroids
Common SE
Hoarseness
Oral Candidiasis (Thrush) -> rinse mouth after each use to prevent
+Inhaled Corticosteroids
(2)
Combination with _____ – reserved for _____ disease
(2)
Budesonide (Pulmicort)
Fluticasone (Flovent)
LABAs – Severe
Fluticasone + Salmeterol (Advair)
Budesonide + Formoterol (Symbicort)
Treatment Algorithm
- Always assess a_______, c______, e______ control
- The use of a SABA > __ days per week should prompt re-evaluation
- Reassess pt __-__ wks after medication ______
- administration, compliance, environmental
- > 2 days/week -> re-evaluate
- 2-6 wks after adjustment
+Treatment Algorithm
All patients need a _____ for ____ therapy
Chronic Treatment (if needed)
- (2)
- Then if that doesn’t work can (3)
- (2) for more severe/refractory disease (why?)
SABA for rescue
- Low dose inhaled steroid (fluticasone) or Leukotriene inhibitor (Singulair)
- Increase dose of inh steroid, add leukotriene inh, or escalate LABA (but LABA should not be the first drug prescribed)
- Oral steroids (prednisone) or IgE antibody - bc alot more SE
Poll 3
COPD
- Progressive, chronic _____ obstruction of airflow secondary to ______ damage
- ______ smoke, occupational ____, p_______, a__
- Associated with chronic ______ response to noxious particles/gases within airways and the lungs
-
irreversible, structural
- tobaccor, dust, pollution age
- inflammatory
COPD Patho
2 types
1) I_____ and _____ can cause bronchiolles to _____, ______ air within the _____ leading to over _____ and r_____
2) ______ is damaged -> inability to transfer __ and ___ -> Lungs cannot supply adequate oxgen to the _____
Chronic Bronchitis
1) Inflammation, fibrosis, collapse, trapping, alveoli, expansion, rupture
Emphysema
2) Elasticity, O2 and CO2, blood
+COPD Treatment
- ______ pharmacological approach to asthma
- Which drug is more commonly seen in COPD vs. asthma (reduces frequency of ______)
- ____ not used in COPD
- ________ usually dosed signficantly higher in COPD
- ________ may be used if infection is present
- _______ ______ may be what causes the pts COPD exacerbation (NOT ALWAYS!)
- Severe disease may require chronic ______ supplementation
- Similar
- Long-acting antimuscarinics, reduces exacerbations
- IgE
- Corticosteroids
- Antibiotics
- Bacterial Pneumonia
- oxygen
- Main diff: COPD’s more so seen with long acting muscarinics (so those drugs usually reserved for severe asthma is used more commonly in COPD)*
- And a lot more steroid use*
Poll 4
Which of the following agents is used routinely as maintenance therapy for COPD, but NOT for asthma
- Salmeterol
- Fluticasone
- IgE
- Tiotropium
Tiotropium
+Hydroxychloroquine Recommendations
Recommended?
Ongoing studies investigating ______
NOT recommended
prophylaxis
Was politicized, but maybe can work early on? With azithro has SE bc they prolong QT
+Remdesivir
MOA
- In vitro data (4)
- _____ data from Ebola studies (n~500)
- First treatment used in a patient case in the ___ for Covid-19
- Clinical Trials with ______
Inhibits viral replication
- Eboa, SARS-Cov-1, MERS-CoV, SARS-CoV-2
- Safety
- US
- RESULTS!
+Remdesivir: 5 v. 10 days
- ______ supplementation evaluated on day ___
- Receiving (1), 14 day mortality _____ in __ day arm
- 5-day 40% mortality vs 10 day 17% mortality
- Oxygen, day 5
- Mechanical Ventilation, higher in 5 day arm
- What we found was no difference in 5 vs 10 days of tx*
- The only diff was with ventilated pts on day 5 of remdesivir -> mortality increased if only given 5 days - so these pts are the only ones given 10 days of tx*
+Remdesivir Recommendations
- ______ Use ______ granted by ___ (May 1, 2020)
- Criteria
- SpO2 < __% on ___ or req ___
- ____ < ____
- Duration of __ days (__ days in intubated)
- _____ disease = weight benefit v. risk
- Monitoring: ___ (must stop if ALT > ____), ____ (can cause transient ____ during infusion)
- Emergency Authorization, FDA
- 94% on RA or req O2
- ALT < 200
- 5, 10 if intubated
- Renal
- LFTs (ALT > 200), BP (hypotension)
- On step of right before FDA approval*
- WE SEE HYPOTENSION, TRANSAMINITIS > monitor ALT daily*
+Remdesivir Recommendations
Conclusion
First line for symptomatic COVID-19
Not a cure, impact better if given early (viral phase)
Inhaled and SQ formulation under investigation
Recommended to give EARLIER in disease
+Steroid Recommendations
Which drug?
What did the studies show?
Dexamethasone
6mg/day showed decreased mortality in COVID pts requiring O2 supplementation
Benefit was NOT seen in pts who did not require O2
+Steroid Recommendations for COVID
- Guidelines suggest using ______ ( or _____/_____ equivalent) at __ mg/day for up to __ days
- Monitoring (4)
- Dexamethasone, (pred/methlypred), 6 mg/day for 10 days
- Hyperglycemia, Bacterial infections, Insomnia, Agitation
Since dex is commonly on shortage
+COVID 19 Conclusion
- ____ agents proposed
- Current guideline recommendations
- Remdesivir (____ the better - think ____ phase)
- Steroids (ideally after __-__ days after _____ onset)
- Convalescent plasma (____ in clinical ___ setting)
- The rest either not recommended or insufficient data to recommend for or against
- Many
- Currently
- earlier, viral
- 5-8 days after symptom onset
- only in trial
Poll 5
- 43F no PMH with an 8 day history of fever, cough, and worsening SOB. In the ED, tested positive for SARS-CoV-2
- When you see the pt you notice she is on 2L NC with a SpO2 94%
- WHich of the following agents would best treat this pt?
- Remdesivir
- Hydroxychloroquine
- Azithromycin
- Dexamethasone
Remdesivir
Dexamethasone
Both but if she wasn’t on oxygen wouldn’t get dex
