Pulmonary Case wrap-up Flashcards
What classes of meds can be used to treat common URI Sx PRN?
- Decongestants
- Pain and fever relievers
- Cough suppressants
- Cough Expectorants
- Vitamins and Supplements
Allergic Rhinitis: meds?
- Antihistamines
- Intranasal Corticosteroids (flonase)
Decongestants: MOA?
–activate _______ and ______ adrenergic receptors
activate alpha and beta adrenergic receptors
Decongestants: MOA
-directly stimulate **alpha-adrenergic receptors of the respiratory mucosa causing ________
** vasoconstriction** which reduces mucosal swelling and improves ventilation
Decongestants: MOA
-directly stimulate beta-adrenergic receptors causing ________
**bronchial relaxation
Decongestants: S/E
Vasoconstriction and tachycardia which can result in angina, HTN, and worsening of CV disease, increase glycogenolysis and gluconeogenesis, and produces CNS stimulation (nervousness, insomnia, dizziness, drowsiness), urinary retention
What Patient populations should AVOID decongestants?
Avoid in HTN pts, <6yo, and first trimester pregnancy
List 2 commonly used decongestant meds
- Pseudoephedrine (Sudafed)
- Phenylephrine (Sudafed PE)
Pseudoephedrine (Sudafed):
- Duration?
- ___% absorbed?
- 4-6 hrs
- 100% absorbed
What did Jaynstein say about Phenylephrine (Sudafed PE)?
- duration is 2-4 hrs
- 38% absorbed
Jaynstein said phenylephrine is worthless, dont even bother cuz it’s poorly absorbed
Cough Suppressants/Antitussives:
MOA: Act at one of two sites:
centrally on the ______
& locally at the _______
Centrally on the medullary cough center–> Dextromethorphan, opiates, Benzonate (Tessalon pearls)
Locally at the site of irritation–>
Lozenges, viscous preparations, menthol and camphor
Dextromethorphan:
- MOA: centrally or locally?
- S/E?
- safe in pregnancy?
Centrally acting (D-isomer of codeine)
–Lower addition profile
SE: **serotonin syndrome, nausea, dizziness, drowsiness
Safe in pregnancy
Dextromethorphan:
AVOID in pts on _____
MAOI’s; (MAOI + dextromethorphan= serotonin syndrome*
-caution in SSRI but not contraindicated
Codeine:
- MOA: centrally or locally?
- S/E?
- safe in pregnancy?
Centrally acting–HIGH abuse potential
SE: CNS depression, respiratory depression, common allergen
**Caution in pregnancy – category C (resp depression, addition risk)
Benzonate (Tessalon):
- MOA: centrally or locally?
- S/E?
- safe in pregnancy?
- Centrally acting
- No addictive properties
-SE: headache, dizziness, drowsiness
Caution in pregnancy – no data
-Either it Works for the Pt or it doesn’t
Expectorants (mucolytic):
list 2 medication ex’s & the MOA
Mucinex and guaifenesin (robitussin)
-MOA: dissolve thick mucus, enhance airway clearing, and promote cough
Robitussin DM=
combo med for dextromethorphan and guaifenesin
Expectorants (mucolytic):
- S/E?
- safe in pregnancy?
- Guaifenesin may exacerbate ______
SE: N/V, rash
Avoid in children <6
Safe in pregnancy
**Guaifenesin may exacerbate nephrolithiasis (kidney stones)
Vitamins and Supplements
for URI tx:
list ex’s and evidence supporting or contraindicating use
Vitamin C: Anecdotal evidence only
Echinacea: EBM does reveal benefit – appears to be most effective in pts with compromised immune systems
Zinc: **EBM contradictory – SE’s common but not life-threatening (nausea, mouth irritation)
Sinusitis: mild-moderate
-treatment?
- Amoxicillin/clavulanate 875mg PO BID 7 days
- Doxycycline 100mg BID x 7 days
Sinusitis: Severe (inpatient)
tx? (several choices)
- Ampicillin/Sulbactam 3gm IV QID
- Levofloxacin 500mg IV QD
- Ceftriaxone (Rocephin) 1gm IV BID
Sinusitis: Risk for resistance or abx failure
tx?
- **Amoxicillin/clavulanate 2000mg BID x 10-14 days
- Levofloxacin 500mg QD x 5 days
- Moxifloxacin 400mg QD x 10 days
Which classes of abx are NOT recommended for empiric therapy for sinusitis due to high rates of resistance to S. Pneumoniae?
Macrolides (clarithromycinorazithromycin),trimethoprim-sulfamethoxazole, and second- or third-generation cephalosporins are not recommended
17 yo female with uncontrolled asthma
–Currently treated w/ Albuterol PRN and Flovent HFA 44mcg
-what questions should you ask her?
- Medication Compliance? Proper use?
- Is she experiencing an acute exacerbation or worsening chronic asthma?–>Hospitalized twice in the last year for poorly controlled asthma; three visits to the ED in the last 6 months
- *uses Albuterol MDI approximately 3–4 days per week over the past 2 months
Pt was Hospitalized twice in the last year for poorly controlled asthma; three visits to the ED in the last 6 months
**uses Albuterol MDI approximately 3–4 days per week over the past 2 months
Asthma classification?
mild persistent/moderate
-categorized as not well controlled asthma
Classification of asthma control (>12 yo):
Well controlled is defined as _______
- Sx less than or equal to 2 days/week
- Nighttime awakenings less than or equal to 2x/month
- SABA use less than or equal to 2 days/week
FEV1= >80% predicted
-0-1 exacerbations per year
Recommended tx:
- maintain current step
- Regular f/u every 6 months to maintain control
- Consider step down if well-controlled for at least 3 months
Classification of asthma control (>12 yo):
Not well controlled is defined as ______
- Sx >2 days/week
- nighttime awakenings: 1-3x/week
- Some limitation of normal activities
- SABA use >2 days/week
- FEV!= 60-80%
- greater or equal to 2 exacerbations/year
Tx: step up 1 step, re-eval in 2-6 weeks
-For S/E: consider alt. tx options
Classification of asthma control (>12 yo):
Very poorly controlled is defined as ______
- Sx throughout the day
- greater or equal to 4 nighttime awakenings/week
- Extremely limited during the day
- SABA use several times a day
- <60% for FEV1
- 2 or more exacerbations per year
tx: Consider short course of PR systemic corticosteroids
- step up 1-2 steps, re-eval in 2 weeks
Step 1: asthma management
(For tx of intermittent asthma Sx)
-SABA PRN
Step 2: asthma management
- low-dose ICS + SABA PRN
- alt: Cromolyn, LTRA
Step 3: asthma management
-low dose ICS +LABA + SABA PRN
or
-Medium dose ICS + SABA PRN
Step 4: asthma management
-medium-dose ICS + LABA + SABA
Step 5: asthma management
high dose ICS + LABA
-IF this does not control Sx well, add in oral corticosteroid and consider Omalizumab
List Ex’s of Inhalation devices that asthma pts can use for asthma management
- Metered-dose inhalers (MDI)
- Dry powder inhalers (DPI)
- Nebulizers
- HFA-diskus
Inhaled Short Acting beta-2-Agonists (SABA):
- MOA: ?
- Onset: ?
- S/E?
MOA: Beta-2 agonist
Onset: 5 min; Peak: 30 – 60 min; Duration: 4 – 6 hrs
SE: Reflex Tachycardia, QTc prolongation, tremor, anxiety, hyperglycemia, hypokalemia and hypomagnesemia, especially if used in high doses
Inhaled Short Acting beta-2-Agonists (SABA):
-list Ex’s of common meds
- Albuterol, Proventil, ProAir, Ventolin
- Xopenex
(albuterol– onset within 5 min, peaks in 30-60 min
-albuterol can cause reflex tach**, and feel jittery )
Inhaled Long Acting beta-2-Agonists (LABA):
MOA: ?
Onset: ?
S/E:
MOA: Beta-2 agonist
Onset: approx. 30 minutes; Duration: > 12 hrs
SE: Paradoxical bronchospasm, asthma exacerbation, laryngospasm, hypokalemia
Inhaled Long Acting beta-2-Agonists (LABA):
list ex’s of common meds
- Salmeterol (Serevent)
- Formoterol
T/F: Monotherapy with an inhaled long-acting beta-2 agonist is not recommended
TRUE. dont do this.
- Black box warning
- An FDA meta-analysis found that use of a LABA was assoc. with increased risk of asthma-related hospitalization, intubation and death; the greatest risk was in children 4-11 years old
-If a LABA is required, it should be used in combination with an ICS, preferably in the same inhaler
Inhaled corticosteroids (ICS):
MOA?
S/E: ?
MOA: Inhibits multiple inflammatory cytokines via the glucocorticoid receptor
SE: Oral candidiasis (thrush), dysphonia, and reflex cough and bronchospasm
Which asthma medication class is the MOST effective long-term tx for control of Sx?
ICS**
ICS: list common meds used
-what do new asthma guidelines state is NOW the standard of care regarding initial meds prescribed?
Qvar, Pulmicort, Flovent
Updated asthma guidelines: ***PRN ICS at initial asthma dx is now standard of care
Laba+Ics combos:
- S/E:
- common medication combinations (list)
SE: Especially if used in higher- than-recommended doses, can cause tremor, muscle cramps, tachycardia and other cardiac effects
Common meds:
-Salmeterol/fluticasone (Advair)
- Formoterol/budesonide (Symbicort)
- Formoterol/mometasone (Dulera)
leukotriene modifiers:
MOA?
=Inhibits physiologic actions of LTD4 at the CysLT1 receptor without any agonist activity.
AKA – block the action of leukotrienes
Leukotrienes–> constriction and mucus production
Leukotriene modifiers are ______ alternatives to low-dose ICS treatment for Pts who are unable or unwilling to use an ICS
less-effective
**also generally less effective than an inhaled LABA as add-on therapy for patients not well controlled on an ICS alone
leukotriene modifiers:
S/E?
list an ex medication name
SE: abdominal pain, nausea, jaundice, itching or lethargy
Common medications:
Singular
*these are NOT a first-line med
mast cell stabilizers:
MOA?
MOA: alters function of delayed Cl- channels and inhibits cell activation
- Inhibition of cough
- Inhibition of early response to antigens (mast cells)
- Inhibition of late response to antigens (eosinophils)
Mast cell stabilizers:
S/E?
Common medication name?
SE: Throat irritation, cough, dry mouth, wheezing, chest tightness
Common medications:
Cromolyn
Failure of pharmacologic treatment in asthma can usually be attributed to:
__________ (list multiple reasons**)
-Lack of adherence to prescribed meds
- Continued exposure to tobacco smoke and other airborne pollutants, allergens or irritants.
- *Smoking and exposure to second-hand smoke can cause airway hyperresponsiveness and decrease the effectiveness of ICSs
-Some Pts w/ asthma may concurrently be taking aspirin or other NSAIDs, or another med that can cause asthma Sx
What oral meds can precipitate bronchospasm in Pts with asthma and DECREASE the bronchodilating effect of beta-2 agonists?
Oral nonselective beta-adrenergic blockers, such as propranolol, timolol
Metoprolol is a selective B1— so it should be ok to use
Addressing co-morbidities
in Asthma Pts:
-Propranolol d/c for migraine prophylaxis?
- Consider d/c propranolol
- *Propranolol is a nonselective β-blocker
- -If you d/c migraine prophylaxis, may replace with metoprolol, amytriptiline, SSRIs,
- Pt is benefiting from migraine prophylaxis tx and d/c would probably exacerbate her migraine condition – alternatives?
- Maximize ICS first, then see…
Alternative migraine prophylactic meds for asthma Pts: (list)
**a non-dihydropyridine CCB, a β1-selective β-blocker, an anticonvulsant, or a TCA
- Potential alternative options for migraine prophylaxis for this Pt include:
- Atenolol 50–100 mg PO daily;
- Metoprolol 100–450 mg PO daily (Note: β1 selectivity may be lost at higher doses within this range);
- Amitriptyline 10–150 mg PO daily;
- Nortriptyline 10–150 mg PO daily;
- Verapamil 80–120 mg PO daily;
- Valproic acid 250–1,500 mg PO daily;
- Topiramate 50–200 mg PO daily.
IF a pt is on an OCP; anticonvulsants can ______ the efficacy of OCP’s – educate (and document!) or choose an different option
decrease**
educate (and document!) or choose an different option
A Pt develops thrush from chronic ICS use, but must continue using the ICS.
What education should be provided and tx?
Educate: rinse mouth after using ICS, use a spacer
Must treat – w/ anti-fungal: nystatin 5 mL swish and swallow QID x 7-14 days
Case: 17 yo female with uncontrolled asthma
-Currently treated with Albuterol PRN and Flovent HFA 44mcg
Tx plan?
- ALWAYS provide a refill prescription for albuterol
- Increase her flovent to 110 mcg, use spacer, discuss compliance
f/u: in 2-4 weeks, guidelines say within 2-6 weeks
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by _______
air flow obstruction that is not fully reversible.
Air flow limitation is usually progressive and associated with an abnormal inflammatory response of lungs to noxious particles or gases, primarily caused by cigarette smoking
**Predominantly caused by smoking
Airflow obstruction is defined as FEV1
- <80%
- <0.7
ratio of FEV1/FVC= <0.7, and FEV1 <80% predicted
Pt with COPD:
- his FEV1 = 2.98L (**predicted 4.02)
- his FVC = 4.5L
FEV1/FVC=
- 98/4.5= 0.66= <0.7
2. 98/4.02= 0.74% = <80%
Classification of Severity of COPD: (in Pts with FEV1/FVC <0.7
GOLD 1
-FEV1 ? Tx?
- mild
- FEV1 >80% predicted
-SABA PRN
Classification of Severity of COPD:
GOLD 2
-FEV1 ? Tx?
Moderate
-50%
Classification of Severity of COPD:
GOLD 3
-FEV1 ? Tx?
SEVERE
30%
Classification of Severity of COPD: GOLD 4
-FEV1 ? Tx?
very severe
FEV1 <30% predicted
- SABA PRN
- ICS + LABA + LAMA
- Tx of complications
- **long term O2 therapy IF chronic failure
- consider surgical tx
Goals of COPD tx:
- drug therapy for chronic for (COPD) are to reduce Sx**
- Control dyspnea
- Improve exercise tolerance and quality of life
- Decrease complications of the disease such as acute exacerbations
Which COPD Pts get a SABA?
combivent=
- **Given to all Pts
- Combining a beta2-agonist with ipratropium has an additive effect. The combo of ipratropium/albuterol has been more effective than either drug alone and is available in a single inhaler.
Combivent= ipratropium bromide and albuterol
Which COPD Pts receive a LABA or LAMA? (list ex meds)
Long-Acting – For patients with evidence of significant airflow obstruction and chronic symptoms, regular tx with a long-acting bronchodilator is recommended (ie LABA or LAMA)
LABAs:
Formoterol (Foradil)
Salmeterol (Serevent)
LAMAs:
Tiotropium (spiriva)
Which COPD Pts get a ICS?
- For Pts w/ severe COPD (FEV <50%) who experience frequent exacerbations while receiving one or more long-acting bronchodilators
- Addition of an ICS is recommended to reduce the number of exacerbations
List ex’s of LABA/ICS combos
Formoterol/Budesonide (Symibcort)
Salmeterol/Fluticasone (Advair)
Vilanterol/Fluticasone (Breo Ellipta)
List ex’s of LAMA/ICS combos:
Vilanterol/Umeclidinium (Anoro Ellipta)
Olodaterol/Tiotropium (Stiolto Respimat)
T/F: Long-term treatment with ORAL corticosteroids is not recommended in COPD
true, dont do this. The risks of such tx include myopathy, glucose intolerance, weight gain and immunosuppression.
Which COPD Pts need O2 therapy? (dx criteria)
- For Pts with severe hypoxemia, use of long-term supplemental O2 therapy has been shown to increase survival and QOL
- O2 may also increase exercise capacity in Pts with mild or moderate hypoxemia, but its long-term benefits in such Pts are unclear
-**Consider for pt’s with: resting O2 <88%RA, evid of pulm HTN, CHF, or polycythemia
COPD:
-benefits of pulmonary rehab?
- benefits of pulmonary rehab programs are well established for patients with COPD
- Pulmonary rehabilitation can reduce dyspnea and improve functional capacity and quality of life, as well as reduce the number of hospitalizations
Pt with GOLD 2 COPD criteria:
tx?
GOLD 2 (group B): SABA + a LABA or LAMA
Plan: Salmeterol (Serevent) or Spiriva, Albuterol PRN
ICS – reserve for groups C & D
Home O2? Not for this Pt, optimize pharmacotherapy first
55yo AA male dx with PNA:
His ABG: pH 7.38; PaCO229; HCO315 mEq/L
GO OVER***
pH: Acidic (7.35)— Basic (7.45)
(normal pH= 7.38)
PaCO2: Acidic (45)— Basic (35, Resp)
HC03: Acidic (22)— Basic(26) metabolic
Acidic nl basic
HCO3 pH CO2
pH closer to acidic then basic –> acidosis
HCO3 is in the acidosis column–> metabolic
Co2= respiratory #
CO3= metabolic
Pt: pH 7.38
Since the PH was closer to the acidic side, you know this is fully compensated metabolic acidosis.
MC pathogens of CAP:
outpatient?
-strep PNA
-Mycoplasma
(Strep and mycoplasma make up 60% of CAP**)
MC pathogens of CAP:
inpatient?
- strep PNA
- M. PNA
CAP Abx:
which abx are best used to treat S. pneumonia?
PCN’s: **high resistance–> Pen VK, Amox, Augmentin
Cephalosporin’s: high resistance to gen 1 and 2
–**3rd gen Ceftriaxone, ceftazidime OK to use
-Macrolides’s: Azithromycin and Clarithromycin
-Fluoroquinolones:
Levofloxacin and Moxifloxacin
- Tetracyclines
- Doxycycline
PCNs should NOT be considered 1st line, same w/ gen 1&2 cephalosporins
-Jaynstein: uses Doxycycline as monotherapy, but macrolides and fluoroquinolones work well too. Or Augmentin + doxy or macrolide
Mycoplasma CAP:
tx?
Tetracycline: Doxycycline OR Macrolide: Erythromycin OR -Fluoroquinolones: Levofloxacin
H. Flu CAP:
tx?
Macrolides: Clarithromycin and azithromycin
Fluoroquinolones: Levofloxacin and Moxifloxacin
Chlamydophilia PNA CAP:
tx?
Macrolides: Clarithromycin and azithromycin
Fluoroquinolones:
Levofloxacin
Legionella PNA:
tx?
Macrolides: Clarithromycin and azithromycin
Fluoroquinolones: Levofloxacin
Second generation Tetracycline:
Doxycycline
PNA tx:
IV vs PO Abx should depend on _____
**the bioavailability of the prescribed drug
–Fluoroquinolones have good bioavailability= no difference btw PO and IV
-ICU pts are usually on antimicrobials which only come in IV form anyway
PNA tx:
when can you switch from IV to PO Abx?
- Pt stable with nl VS x 24 hours (afebrile, respiratory rate ≤24 breaths/minute, heart rate ≤100 bpm, systolic blood pressure ≥90 mm Hg, O2 sat >90%RA)
- No resp distress
IV vs PO Abx for PNA tx:
EBM states that approx. ___% of Pts admitted for IV abx can be switched to PO abx within ____ days
40-50% of patients admitted for intravenous antibiotics can be switched to oral antibiotics within 2-3 days
Pearl: just bc a pt is hospitalized for PNA does NOT mean they need IV abx’s
- Hypoxia/resp distress
- Monitoring for improvement
- Mod to high risk for decompensating
CURB-65 criteria:
1 point given for each of:
- Confusion
- Urea (>7 mmol/L)
- RR (greater or equal to 30/min)
- BP (SBP <90 or DBP less than or equal to 60)
- Age (greater or equal to 65yo)
- score of 0-1: outpatient tx
- score of 2: short hospital stay/supervised outpatient
- score of 3 or more: Hospital, assess for ICU
The results of the patient’s sputum culture reveal the presence of PSSP (penicillin MIC ≤2 mcg/mL). The susceptibility results also demonstrate that the S. pneumoniae is sensitive to ceftriaxone (MIC ≤0.06 mcg/mL), levofloxacin (MIC ≤0.5 mcg/mL), and vancomycin (MIC ≤1 mcg/mL) but is resistant to erythromycin.
Therefore, the patient can remain on: _____
ceftriaxone therapy during his hospitalization and the azithromycin can be discontinued.
D/C Pt w/: An oral cephalosporin or fluoroquinolone
Cefpodoxime 200 mg PO Q 12 H
✓Cefprozil 500 mg PO Q 12 H
✓Cefuroxime axetil 500 mg PO Q 12 H
✓Cefdinir 300 mg PO Q 12 H- is the best, but it’s more expensive
✓Cefditoren 400 mg PO Q 12 H
-Levofloxacin 750 mg PO daily- IV and PO forms so good for this pt to use out pt
55yo AA male dx with PNA:
tx plan and f/u after his hospitalization and started on IV abx:
- f/u with PCP in 5 days
- CXR should be repeated – would recommend CXR just prior to d/c and again for resolution
- Finish full course of ABX (5-7 days of levo is good)
–Can alternate APAP 1gm with IBU 600mg Q 4 hours for fever and body aches
- Stay well hydrated
- Go to the ER for chest pain, trouble breathing, fever > 102, leg swelling, calf pain, or for any other concerns.
