Pulmonary-Obstructive Disease

Question 1

Delivery Methods for Respiratory Meds

Answer 1

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

Question 2

MDI technique

Answer 2

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

Question 3

DPI Technique

Answer 3

prep device, exhale normally, inhale deeply and QUICKLY, hold breath, exhale, and rinse mouth if corticosteroid
-likely not useful for those acutely SOB

Question 4

Asthma Patho

Answer 4

• 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)

Question 5

Controllers vs Rescue Meds

Answer 5

• 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

Question 6

Beta Agonists in Pulmonary Disease

Answer 6

• 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

Question 7

short acting beta agonists

Answer 7

administered by MDI, HFA, or neb
-SE: hypokalemia, tremor, tachycardia
Albuterol, levabuterol

Question 8

Abuterol vs Lavalbuterol

Answer 8

• 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

Question 9

Long Acting Beta Agonist

Answer 9

-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

Question 10

Anticholinergics in Pulmonary Disease

Answer 10

-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

Question 11

Corticosteroids in Pulmonary Disease

Answer 11

-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

Question 12

Corticosteroids and Ritonavir

Answer 12

can lead to cushing’s syndrome

Question 13

Leukotriene Inhibitors in Pulmonary Disease

Answer 13

-MOA: inhibit leukotriene synthesis or block its receptor. Leukotrienes trigger constriction of bronchioles.
-SE: Churg-Strauss and liver dx
-administered orally
Monolukast and Zileuton

Question 14

Methylxanthines in Pulmonary Disease

Answer 14

-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

Question 15

Anti-IgE Medications in Pulmonary Disease

Answer 15

-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

Question 16

Stepwise Pharmacological Asthma Control

Answer 16

-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

Question 17

Management of Asthma Exacerbations

Answer 17

• SABA and/or anticholinergic (duoneb)
• IV/oral steroids
• IV mag sulfate

Question 18

COPD patho

Answer 18

• smoking leads to inflammation, thickened and narrowed airways, alveolar distruction, and excess mucous
• leads to emphysema and chronic bronchitis

Question 19

Differentiating COPD and Asthma

Test Question

Answer 19

• 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

Question 20

Pharmacological Mgmt of COPD

Answer 20

• Rescue Meds: SABA and anticholinergic

- Control: LABA, LA anticholinergic, ICS, theophylline, PDE4 inhibitor

Question 21

Phosphodiesterase 4 Inhibitors

Answer 21

-MOA: phosphodiesterases inhibit the degradation of cAMP (cAMP relaxes smooth muscle).
-administered orally
-SE: GI upset, diarrhea, weight loss
Roflumilast

Question 22

Management of COPD

Answer 22

-SABA is the mainstay, add LABA, then steroid, then O2 and surgical tx

Question 23

Key difference in MANAGEMENT of COPD vs Asthma

Answer 23

• Asthma calls for steroid before addition of LABA

- COPD calls for LABA before ICS

Question 24

Treatment of COPD exacerbation

Answer 24

• SABA and anticholinergic (Duoneb)
• Systemic steroids (IV/PO equally effective) for five days (no need to taper)
• Antibiotics

Question 25

Key difference in Tx of COPD vs Asthma

Answer 25

• Both call for SABA/anticholinergic and systemic steroids

- Asthma calls for Mag Sulfate while COPD calls for ABX

Question 26

Why Use ABX in COPD Pts Having an Exacerbation?

Answer 26

• many COPD exacerbations are the result of infection

- choose ABX with anti-inflammatory properties such as azithromycin, doxycycline, TMP/SMX(Bactrim) for 5 days

Question 27

Remember the Endings for these Common Classes

Answer 27

Beta agonists: -erol
Anticholinergics: -ium
Steroids: -sone

Question 28

Cystic Fibrosis Patho

Answer 28

-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

Question 29

Cystic Fibrosis Treatment Strategies

Answer 29

• increase airway clearance through CPT, postural drainage, oscillation, and exercise
• limit bacterial infection
• anti-inflammatory abx
• lung transplant

Question 30

Pharmacological Measures for CF

Answer 30

• Inhaled DNase and hypertonic saline to limit secretions
• nebulized tobramycin to treat pseudomonas
• Macrolide ABX (azithomycin) to decrease inflammation