Pulmonary-Obstructive Disease Flashcards
Delivery Methods for Respiratory Meds
Dry Powder Inhalers- disks, require 30-60L inspiration
Metered Dose Inhalers- puffers
Nebulizers- administered with regular tidaled breathing, so does not require pt cooperation, but is more expensive
MDI technique
Shake MDI and prime new cannisters, hold upright, breathe out normally, press down cannister, breathe in deeply and SLOWLY, hold breath for 5-10 seconds
SPACER improves distal delivery and minimizes timing importance. Should be used with every MDI
DPI Technique
prep device, exhale normally, inhale deeply and QUICKLY, hold breath, exhale, and rinse mouth if corticosteroid
-likely not useful for those acutely SOB
Asthma Patho
- Allergens (IgE) activate mast cells, T lymphocytes, eosinophils, neutrophils, which lead to inflammation, airway constriction, and mucous production
- generally there is a balance of bronchial tone mediated by cAMP, ACh, and adenosine (these are the different pathways of pharmacological actions)
Controllers vs Rescue Meds
- Educate patients on the difference.
- Rescue meds are short acting and work only when symptoms have started
- Control meds are long-acting and prevent the occurrence of symptoms
- Know which meds are control and rescue
Beta Agonists in Pulmonary Disease
- MOA: B2 relaxes smooth muscles, decreases plasma leakage, decreases cholinergic response, increases ciliary action, decreases bacterial adhesion, and decreases neutrophil activity.
- basically increases cAMP which bronchodilates by inhibiting adenylate cyclase
short acting beta agonists
administered by MDI, HFA, or neb
-SE: hypokalemia, tremor, tachycardia
Albuterol, levabuterol
Abuterol vs Lavalbuterol
- initially it was thought that levabuterol was more active, but ultimately they are equally effective much more expensive
- levabuterol may be a better choice for those with tachycardia
Long Acting Beta Agonist
-administered by DPI
-SE: HA, throat irritation
Salmeterol and Formoterol
-DO NOT USE ALONE FOR ASTHMA R/T BLACK BOX RISK OF DEATH (especially in AA population)
-use with steroid in asthma, can be used alone in COPD
Anticholinergics in Pulmonary Disease
-MOA: blocks muscarinic receptors on smooth muscle to decrease bronchoconstriction
-administered by MDI, neb, handihaler, or pressair
-CONTRAINDICATIONS: glaucoma, prostate hypertrophy, MG
Iprotropium/atrovent for COPD or asthma
Tiotropium and aclindinium for COPD only
Corticosteroids in Pulmonary Disease
-MOA: blocks the actions of inflammatory cells by altering gene transcription
-administered orally, IV, or inhaled
-SE: PNEUMONIA, osteroporosis, thrush, cataracts, voice changes
Fluticasone, Budesonide, Beclomethasone, Mometasone
Corticosteroids and Ritonavir
can lead to cushing’s syndrome
Leukotriene Inhibitors in Pulmonary Disease
-MOA: inhibit leukotriene synthesis or block its receptor. Leukotrienes trigger constriction of bronchioles.
-SE: Churg-Strauss and liver dx
-administered orally
Monolukast and Zileuton
Methylxanthines in Pulmonary Disease
-MOA: inhibit PDE (breaks down cAMP), inhibit adenosine, and activate histone deacetylase to relax bronchioles
-administered orally
-SE: tachycardia, NV, and seizures
-narrow therapeutic window, must follow levels
Theophylline
Anti-IgE Medications in Pulmonary Disease
-MOA: blocks IgE’s proinflammatory signaling to limit effects of extrinsic allergens
-administered SQ
-SE: local reactions and anaphylaxis
-used for severe asthma or those who have high IgE levels b/c it is very expensive
Omalizumab
Stepwise Pharmacological Asthma Control
-having 2 or more episodes of symptoms or needing to use rescue meds 2 times per week indicates the need to step up.
SABA prn is the baseline, add in low dose inhaled steroid, then add LABA, then Medium dose steroid and LABA, then high dose steroid with LABA, and finally all of the above with oral steroid.
-if controlled for 3 months, step down
-INHALED STEROIDS ARE CORNERSTONE OF THERAPY
-do not add LABA without steroid on board
Management of Asthma Exacerbations
- SABA and/or anticholinergic (duoneb)
- IV/oral steroids
- IV mag sulfate
COPD patho
- smoking leads to inflammation, thickened and narrowed airways, alveolar distruction, and excess mucous
- leads to emphysema and chronic bronchitis
Differentiating COPD and Asthma
Test Question
- Asthma onset is earlier in life (30 vs 40)
- Cough in asthma is nocturnal or after exercise as opposed to in the morning (COPD)
- atopy is prominent in asthma
- bronchodilators reverse symptoms well in asthma
- asthma responds well to steroids
- asthma runs in the family
- asthma symptoms are intermittent rather than progressive and constant
- asthma’s first line control tx is inhaled steroid vs LABA and anticholinergic
- purulent sputum is common in COPD
- smoking is not highly associated with asthma as opposed to COPD
Pharmacological Mgmt of COPD
- Rescue Meds: SABA and anticholinergic
- Control: LABA, LA anticholinergic, ICS, theophylline, PDE4 inhibitor
Phosphodiesterase 4 Inhibitors
-MOA: phosphodiesterases inhibit the degradation of cAMP (cAMP relaxes smooth muscle).
-administered orally
-SE: GI upset, diarrhea, weight loss
Roflumilast
Management of COPD
-SABA is the mainstay, add LABA, then steroid, then O2 and surgical tx
Key difference in MANAGEMENT of COPD vs Asthma
- Asthma calls for steroid before addition of LABA
- COPD calls for LABA before ICS
Treatment of COPD exacerbation
- SABA and anticholinergic (Duoneb)
- Systemic steroids (IV/PO equally effective) for five days (no need to taper)
- Antibiotics
Key difference in Tx of COPD vs Asthma
- Both call for SABA/anticholinergic and systemic steroids
- Asthma calls for Mag Sulfate while COPD calls for ABX
Why Use ABX in COPD Pts Having an Exacerbation?
- many COPD exacerbations are the result of infection
- choose ABX with anti-inflammatory properties such as azithromycin, doxycycline, TMP/SMX(Bactrim) for 5 days
Remember the Endings for these Common Classes
Beta agonists: -erol
Anticholinergics: -ium
Steroids: -sone
Cystic Fibrosis Patho
-CF transmembrane gene mutation leads to loss of airway surface liquid and increase in mucous secretion. Ciliary action is decreased leading to frequent bacterial infections
Cystic Fibrosis Treatment Strategies
- increase airway clearance through CPT, postural drainage, oscillation, and exercise
- limit bacterial infection
- anti-inflammatory abx
- lung transplant
Pharmacological Measures for CF
- Inhaled DNase and hypertonic saline to limit secretions
- nebulized tobramycin to treat pseudomonas
- Macrolide ABX (azithomycin) to decrease inflammation
