Pulmonary Conditions & Tobacco Cessation Flashcards
What is pulmonary arterial htn?
-high BP in pulmonary artery (mPAP > 25)
-diagnosed with a right heart catheterization
–> imbalance of vasoconstrictor/vasodilators, imbalance of proliferation/apoptosis = enlarged right ventricle and right heart failure
Symptoms: fatigue, dyspnea, chest apin, syncope, edema, raynaud’s phenomenon
drugs that can cause PAH?
-cocaine and methamphetamines
-fenfluramine
-SSRI use during pregnancy (can inc risk of persistent pulmonary htn of a newborn)
-weight loss drugs (phentermine, diethylpropion, phendimetrazine)
Treatment of PAH
Non-drug: sodium restriction and immunizations
Drug:
-start: warfarin (INR 1.5-2.5) +/- diuretics +/- oxygen +/- Digoxin –> right heart cath and acute vasoactive testing =
+ : oral CCB (not verapamil)
- : begin a PAH approved drug
—> PDE-5 inhibitor
–> endothelin receptor antagonist
–> soluble guanylate cyclase stimulator
–> prostacyclin analogue
Prostacyclin analogues & receptor agonists for PAH
–> potent vasodilators (pulmonary and systemic) and platelet inhibitors
- Epoprostenol (Flolan) - ~ 5 min 1/2 life, PROTECT FROM LIGHT, ice pack for stability
- Trepostinil
- IIoprost (Ventavisa)
-Selexipag (Uptravi)
SEs: vasodilatroy, GI, anxiety, chest pain/palps, edema, jaw pain, neuropathy, site pain w. SC treprostiril, cought w/ inhaled products
**life-threatening is stopped suddenly!
Endothelin Receptor Antagonists (ERAs) for PAH
–> blocks endothelin, a vasoconstrictor with proliferative effects
- Bosentan (Tracleer)
- Ambrisentan (Letairis)
- Macitentan (Opsumit)
BBW: restricted access programs: embryo-fetal toxicity, Bosentan: hepatotoxicity
SEs: headahce, edema, hypotension, flushing
Phosphodiesterase-5 (PDE-5) Inhibitors for PAH
–> cause pulmonary vasculature relaxation and vasodilation
-Sildenafil (Revatio): 20 mg TID, taken 4-6 hhrs apart, avoid use for PAH in pts taking PI-based regimens
-Tadalafil (Adcira): 40 mg daily, avoid if crcl < 30
SE: dizziness, hypotension, headache
CI w/ nitrates
Soluble Guanglate Cyclase (sCG) stimulator for PAH
-Riocigulat (Adempas)
- used for group 1 and group 4
–> lots of drug interactions!
Select drugs that can cause pulmonary fibrosis*
-Amiodarone/dronedarone
-Bleomycin
-Busulfan
-Carmustine
-Lomustine
-Nitrofurantoin
-Sulfalazine
Pulmonary Fibrosis
-presents as exertional dyspnea with nonproductive cough
Drugs that tx: pirfenidone (Esbriet) and nontedanib (Ofev) –> slow the rate of lung function decline
Diagnosis and assessment of Asthma
via spirometry
-FEV1: how much air can be forcefully exhaled in 1 second
-FVC: the max volume of air that is exhaled after taking a deep breath
-FEV1/FVC: the percentage of total air capacity (vital capacity) that can be forcefully exhaled in 1 sec
Criteria: measure FEV1 –> give bronchodilator –> measure FEV1 –> inc FEV1 > 12% = reversibility/diagnosis
Initial asthma assessment (symptom frequency per step & rescue inhaler use)
Step 1:
–> < 2 times per month daytime
–> no nighttime
- < 2 days/week
Step 2:
–> > 2x/month daytime
–> < 4-5 days/day nighttime
- > 2 days/week but not daily or >1 x/day
Step 3:
–> most days
–> >1 x/week nighttime
-daily
Steps 4&5:
–> daily
–> > 1x/week nighttime
-several times per day
Asthma Treatment Algorithm: step 1
-symptoms < 2x/month
–> PRN low dose ICS + formoterol
OR
–> low dose ICS + SABA
Asthma Treatment Algorithm: step 2
-symptoms/need for SABA 2x/month
–> low dose ISC daily
OR
–> low dose ICS + SABA
Asthma Treatment Algorithm: Step 3
-symptoms on most days or waking at night >1 x/week
–> low dose ISC + LABA
Asthma Treatment Algorithm: Step 4
-daily symptoms, waking at night > 1x/week
–> medium dose ICS + LABA
Asthma Treatment Algorithm: step 5
-severe persistent
–> high. dose ICS + LABA
-refer for assessment
Beta 2 agonists: SABAs
–> albuterol, levalbuterol
-PRN use only, not rec to use SABA alone
-200 inhalations/canister
-ProAir RespiClick: dry powder formulation
-Primatene Mist- OTC epinephrine
SEs: nervousness/tremor, tachycardia, palpitations, cough, inc BG, dec K
Controller/Maintenance Inhalers for asthma: ICS
–> Beclomethasone (QVAR RediHaler)
–> Budesonide (Pulmocort Flexhaler)
–> Fluticasone (Flovant HFA, Flovant Discus, Arnuity Ellipta)
Beta-2 Agonists: LABAs
–> salmeterol, formoterol
BBW: inc risk of asthma related death when used as monotherapy
-only use as add on to ICS therapy
-formoterol used for rescue WITH ICS
SEs: nervousness/tremor, tachycardia, palpitations, cough, inc BG, dec K
Inhaled corticosteroids for asthma
–> 1st line tx for persistant asthma for all pts, even children
-used PRN w/ fomoterol or SABA for rescue
Warnings: adrenal suppression w/ prolonged use of high doses = growth retardation in children
SEs: dysphonia, oral candidiasis (thrush), cough, inc BG
-Beclomethasone (QVAR RediHaler)
-Budesonide (Pulmicort Flexhaler)
-Fluticasone (Flovant HFA)
Controller/Maintenance Inhalers for COPD: ICS
there is no single ICS product that is FDA approved for COPD
Controller/Maintenance Inhalers for asthma: LABA
Salmeterol (Serevent discus)
Controller/Maintenance Inhalers for COPD: LABA
-Salmetrol (servent discus)
-Formoterol (Performomist - neb)
-Arfomoterol (Brovana - neb)
-Olodaterol (Striverdi Respimet)
Controller/Maintenance Inhalers for asthma: LAMA
Tiotropium (Spirivia Respimet)
Controller/Maintenance Inhalers for COPD: LAMA
-Tiotropium (Spiriva HandiHaler, Spiriva Respimet)
-Adidinium (Tudorza Pressair)
-Glycopyrrolate (Lonhala magnair- neb)
-Revefenacin *Yuperli-neb)
-Umeclidinium (Incruse Ellipta)
Controller/Maintenance Inhalers for asthma: ICS/LABA
-Budesonide/formoterol (Symbicort)
-Fluticasone/salmeterol (Advair Discus, Advair HFA)
-Mometasone/formoterol (Dulera)
-Fluticasone/Vilanterol. (Breo Ellipta)
Controller/Maintenance Inhalers for COPD: ISC/LABA
-Budesonide/formoterol (Symbicort)
-Fluticasone/salmetrol (Advair Diskus)
-Fluuticasone/vilanterol (Brea Ellipta)
Controller/Maintenance Inhalers for asthma: LABA/LAMA
-none are FDA approved
Controller/Maintenance Inhalers for COPD: LABA/LAMA
-Aclidinium/formoterol (Duaklir Pressir)
-Glycopyrrolate/formoterol (Bevespi Aerosphere)
-Tiopropium/olodaterol (Stiolato Respimat)
-Umelidinium/vilanterol (Anoro Ellipta)
Controller/Maintenance Inhalers for asthma: LABA/LAMA/ICS
umelclidinium/vilanterol/fluticasone (Trelegy Ellipta)
Controller/Maintenance Inhalers for COPD: LABA/ALAMA/ICS
-umelclidinium/vilanterol/fluticasone (Trelegy Ellipta)
-Glycopyrrolate/formoterol/budesonide (Breztri Aerosphere)
MDI inhalers*
-HFA, Respimat or no suffix (Symbicort, Dulera)
-aerosolized liquid
-some use a propellant (HFA)
-take slow deep inhalation while preparing the canister
-spacer can be used
-shake all products EXCEPT QVAR handHaler, Alvesco and Respimat products
-prime before first use and if not used for a certain period of time
DPI Inhalers*
-Brand names: Diskus, Ellipta, Pressair, HandiHaler, RespiClick, Flexhaler
-fine powder
-no propellant- needs forceful inhale
-admin via fast inhale
-spacer cannot be used
-do not shake
-priming is not needed except for Flexhaler
Leukotriene Modifying agents for asthma
–>Montelukast (Singulair)
- 1 yr and older
-take in the evening
-neuropsychriatic events
–> Zafirlukast (Accolate)
–> Zileuton (Zyflo)
-liver damage
Theophylline for asthma
-dosed using IBW (if TBW < IBW- use total)
SE: nausea, headache, tachycardia, insomnia, tremor
Toxicity = arrhythmias, seizures
-conversion to aminophylline (Amino To Theoph Mult by 0.8)
-range = 5-15 mcg/mL*
Anticholinergics (Inhaled muscarinic anntagonists) for anthma
Tiotropium (Spiriva Respimat) for pts 6 yrs and older
Monocolnal antibodies (parenteral products) for asthma
-Omalizumab (Xolair) blocks IgE binding to the IgE receptors on mast cekks
BBW: anaphylaxis- must be given in healthcare setting
-indicated for moderate to severe allergic asthma
-given SQ q 2-4 weeks
Interleukin receptor antagonists for asthma
–> indicated for severe asthma with an eosinophilic phenotype
-Mepolzumab (Nucala): SC q 4 w
-Reslizumab (Cinqair): IV q 4 weeks
-Benralizumab (Fasenra): SC q 8w
-Dupilumab (Dupixent) sc q 2 w
Asthma control in pregnancy
-down titration of meds not necessary
-rescue inhaler is a must!
-preferred controllers: ICS (typically budesonide)
spacers for asthma
-helpful for children and anyone that has difficulty with hand-breath coordination with an MDI
-plus, spacers reduce the risk of thrush from ICS
–> ex: AeroChmaber, OptiHaler, OptiChamber
Peak Flow Meter
-green zone = >80-100%: indicates all clear/good control
-Yellow zone = 50-80%: indicates caution, worsening lung function
-Red zone = <50% personal best: indicated medical alter, seek medical attention
-action of plan - rescue inhaler, ED visit
-measure PEFR in the am when pt wakes- before asthma meds
Counseling tips: Ventalin HFA, Proair HFA
-rinse mouth piece with warm water, clean at least weekly
-shake and spray 4 times to prime
Diagnosis of Asthma
-age of onset usually < 40 y/o
-smoking hx uncommon
-sputum production infrequent
-allergies common
-intermittent/variable symptoms
-stable disease (does not worsen over time)
-exacerbations common
-first line tx: ICS
Diagnosis of COPD
-age of onset > 40 y/o
-smoking hx usually > 10 yrs
-sputum production common
-allergies uncommon
-persistent symptoms
-disease worsens over time
-exacerbation common
-first line tx: bronchodilators
COPD tx: Group A
-CAT <10, mMRC 0-1 with 0-1 exacerbations with NO hospitalization
-bronchodilator (preferred)
-SABA or SAMA (PRN), LABA or LAMA
COPD tx: Group B
-CAT > 10, mMRC > 2 with 0-1 exacerbations with NO hospitalization
LAMA or LABA
COPD tx: Group C
CAT < 10, mMRC 0-1 with >2 or > 1 exacerbations that lead to hospitalizations
-LAMA
COPD tx: Group D
CAT > 10, mMRC > 2 with >2 or > 1 exacerbations that lead to hospitalizations
-LAMA
-LAMA + LABA
-LABA + ICS (if eos > 300 cells)
COPD escalation of treatment: Dyspnea
LAMA or LABA –> LAMA + LABA –> switch inhalers, check for other causes
COPD escalation of treatment: Exacerbations
LAMA or LABA —>
Path 1: EOS > 300: LABA + ICS –> consider roflumilast or azithromycin
Path 2: EOS < 300: LAMA + LABA –>
-EOS > 100: LAMA + LABA + ICS –> consider roflumilast or azithromycin
-EOS < 100: consider roflumilast or azithromycin
COPD: short acting muscarinic antagonists (SAMAs)
-Ipratropium bromide (Atrovent HFA)
-Ipratropium bromide + albuterol (Combivent Respimat)
-QID dosing
SE: dry mouth, avoid spraying in the eyes
COPD: Long acting muscarinic antagonists (LAMAs)
-Tiopropium (Spirivia HanidHaler, Sprivia Respimat)
-Glycopyrrolate/fomoterol/budesonide (Breztri Aerosphere)
-Umeclidinium/velantrol/fluticasone (Trelegy Ellipta)
-daily ( 2 puffs) dosing
SE: dry mouth, avoid spraying in the eyes
COPD: Long acting beta-2 agonists (LABAs)
-salmerterol/fluticasone (Advair Diskus)
-formoterol/budesonide (Symbicort)
-formoterol/glycopyrrolate/budesonie (Breztri Aerosphere)
-Vilanterol/fluticasone (Breo Ellipta)
-Vilanterol/umeclidinium/flutivasone (Trelegy Ellipta)
BBW: asthma related death when used alone
SEs: nervousness/tremor, tachycardia, palpitations, cough, inc BG, dec K
COPD: Phosphodiesterase-4 inhibitor
–> Roflumilast (Daliresp)
-oral tab taken daily
-should be used with at least one long acting bronchodilator
CI: moderate-severe liver impairment
SE: diarrhea, weight loss
Drug interactions!!
Pack-year smoking hx formula
(cig packs)/day * number of yrs smoked
what enzyme does smoking induce?
CYP1A2 –> if you take a CYP1A2 substrate (liek warfarin) = decreased substrate concentrations
Women > 35 y/o and smoking:
should NOT take estrogen-containing oral contraceptives = inc risk of cardiovascular events
Vaccinations in smokers
-annual influenza vaccine is rec for all persons
-smokers age 19-64 should also receive: Pneumococcal vaccine
–> Prevnar 20 (PCV20)
–> Vaxneuvance (PCV15) followed by Pneumovax 23 (PPSV23)
Nicotine replacement therapy: OTC
-Nicotine patch (Nicoderm CQ)- remove before MRI
-Nicotine gum (Nicorette)
-Nicotine lozenge (Nicorette Mini)
-gum and lozenge = sugar free, in 4 mg dose can reduce or delay weight gain
Nicotine replacement therapy: RX
-nicotine inhaler (Nicotrol)
-nicotine nasal spray (Nicotrol NS)
Nicotine replacement therapy SEs
Warnings: avoid in immediate post MI period, life-threatening arrhythmias, angina and pregnancy
SE: insomnia, nervousness, HA, patch= vivid dreams
Nicotine patch dosing: smokes > 10 cig/day
Start: 21 mg patch x 6 weeks –> 14 mg patch x 2 weeks –> 7 mg patch x 2 weeks
-can be longer than 10 week duration, can be used indefinitely
Nicotine Patch Dosing: smokes </ 10 cigs per day
start: 14 mg patch x 6 weeks –> 7 mg patch x 2 weeks
Nicotine gum/lozenge dosing: 1st cig < 30 mins after waking
Start (>9 pieces/day in first 6 weeks): 4 mg Q 1-2 H x 6 w –> 4 mg Q2-4 H x 3 w –> 4 mg Q 4-8 H x 3 w
Nicotine gum/lozenge dosing: smokes 1st cig > 30 mins after waking
Start (>9 pieces/day in first 6 weeks): 2 mg Q1-2H x 6 weeks –> 2 mg Q2-4H x 3 weeks –> 2 mg Q4-8H x 3 weeks
Bupropion SR (Zyban)
-12 hr formulation
-start at least 1 week before quit fate: 150 mg QAM for 3 days, then 150 mg BID (MDD: 300 mg), use for up to 6 months, no need for taper
BBW: suicidal thinking in those < 24 y/o
CI: seizure disorder, anorexia/bulimia, use with MAOi, linezolid, meth blue,, do not use with any other form of bupropion
SE: serious neuro events, dry mouth, insomnia (take in the am), tremors and weight loss
Varenicline (Chantix)
-blocks nicotine from binding
-0.5 mg tabs (11) 1 mg tab (42) - has taper up schedule
-use for 12 weeks
Warnings: serious neuro symptoms, seizures
SE: nausea (take after food w/ full glass of water), insomnia, abnormal dreams
Treatment considerations for tobacoo cessation
-Weight gain? use NRT gum, lozenge (4 mg dose), bupropion SR
-Depression? use Bupropion SR
-Dentures? avoid gum
-Asthma/COPD?: avoid NRT inhaler and nasal spray
-skin conditions? avoid patch
-seizures? avoid Bupropion, varenicline
Nicotine Patch Administration
-remove patch, save pouch
-apply the sticky side of patch to a clean, dry area
-press patch firmly into skin for ~10 secs
-wear for 24 hrs
-fold sticky ends together, place in pouch to discard
-rotate the application site
-never cut the patch and remove before an MRI
How to chew nicotine gum
-chew slowly until tingle or pepprey flavor
-park gum in between the cheek and gum line
-when tingle/flavor goes away, chew until it returns
-park again between cheek and gum line
-repeat cycle until most of the tingle/flavor is gone
-do not eat/drink for 15 min before or while chewing
