Pulmonology Flashcards
FEV1 definition
volume of air exhaled forcefully in the first second of maximal expiration
Normal >=80%
FEV1 and FVC in asthma
FEV1 will increase >=12%
or
FVC will increase >=200 mL
after administration of SABA. This shows reversibility of asthma
FVC definition
maximum volume of air that can be exhaled after full inspiration
reported in liters and percentage predicted
i.e. adults can empty 80% air in <6 seconds
FEV1/FCV ratio
percentage of lung capacity able to be expelled in one second
normal is about 75-80%(varies) in adults
COPD: <70%
Asthma s/s
-Triggers: laughing, exercise, allergens, seasonal
-Onset <40 y/o
-Improve with bronchodilator
Asthma initial treatment
ICS-containing treatment essential
Do not give LABA or LAMA without ICS!
COPD s/s
-Persistent dyspnea on most days
->40 y/o
-cough/sputum
-with or without bronchodilator reversiblity
COPD initial treatment
Avoid high-dose ICS and maintenance steroids
Treat as COPD per GOLD guidelines
Intermittent asthma (frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.)
Frequency of symptoms: <=2 days/week
Nighttime awakenings: <=2times/mo
SABA use: <=2 days/week
No interference with daily activities
FEV1/FVC: normal to >85%
FEV1: normal
Exacerbations requiring oral steroids: 0-1/yr
Initial therapy: step 1
Step 1 Asthma therapy
SABA prn
If controlled: mild asthma
Step 2 Asthma therapy
Maintenance: Low dose ICS OR low-dose ICS + SABA prn
Rescue: low-dose ICS + SABA prn
Alt: SABA prn
Conditionally recommend SC immunotherapy if controlled
If controlled: mild asthma
Step 3 Asthma therapy
low-dose ICS+formoterol
Rescue: low-dose ICS + formoterol PRN
Alt: SABA prn
Conditionally recommend adjunct SC immunotherapy if controlled
If controlled: moderate asthma
Step 4 Asthma therapy
Medium-dose ICS + formoterol
Rescue: Medium-dose ICS-formoterol PRN
Alt: SABA prn
Conditionally recommend adjust SC immunotherapy if controlled
If controlled or remains uncontrolled: severe
Step 5 Asthma therapy
Medium/high-dose ICS-LABA + LAMA
Rescue: SABA prn
Consider asthma biologic
If controlled or remains uncontrolled: severe
Step 6 Asthma therapy
High-dose ICS-LABA + OCS
Rescue: SABA prn
Consider asthma biologic
Well-controlled asthma
NO
-daytime asthma symptoms
-night waking
-SABA need
-activity limitation
Partly controlled asthma
1 or 2 present:
-daytime asthma symptoms >2x/wk
-Night waking
-SABA need >2x/wk
-Activity limitation
Uncontrolled asthma
3 or 4 present:
-daytime asthma symptoms >2x/wk
-Night waking
-SABA need >2x/wk
-Activity limitation
Mild persistent asthma ((frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.))
Frequency: >2 days/week (not daily)
Nighttime awakening: 3-4x/mo (1-2x if 0-4)
SABA use >2days/wk (not daily)
Minor limitation with normal activity
FEV/FVC normal
Exacerbations req. steroids: >=2/yr (if 0-4y/o then >=2 in 6 mo)
Initial treatment: step 2
Moderate persistant asthma (frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.)
Frequency: daily
Nighttime awakening: >1x/wk, not nightly
SABA use: daily
Some limitations
FEV/FVC: reduced 5%
FEV >60 <80%
Exac req. steroids: >=2/yr (if 0-4 y/o then >=2/6mo)
Initial treatment step 3. Consider short course of PO steroids
Severe persistent asthma (frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.)
Frequency: throughout the day
Nighttime awakening: often nightly
SABA use: several times/day
Extremely limited normal activity
FEV/FVC reduced >5%
FEV <60%
Exac req. steroids: >=2/yr (if 0-4, >=2/6 mo)
Initial treatment, all consider short course of oral steroids:
>=12: Step 4 or 5
5-11: Step 3 or 4
0-4: Step 3
low dose ICS
> 12 y/o only
beclomethasone: 100-200mcg/day
budesonide: 200-400mcg/day
ciclesonide: 80-160mcg/day
fluticasone propionate: 100-250mcg/day
fluticasone furoate: 100mcg/day
mometasone: 100-220mcg/day (twisthaler) or 200-400 mcg/day (HFA)
Use for Step 2-3
Medium dose ICS
> 12y/o only
beclomethasone: >200-400mcg/day
budesonide: >400-800mcg/day
ciclesonide: >160-320mcg/day
fluticasone propionate: >250-500mcg/day
fluticasone furoate: N/A
mometasone: >220-440mcg/day (twisthaler)
Use for step 4 or 5
High dose ICS
> 12 y/o only
beclomethasone: >400mcg/day
budesonide: >800mcg/day
ciclesonide: >320mcg/day
fluticasone propionate: >500mcg/day
fluticasone furoate: 200mcg/day
mometasone: >440mcg/day (twisthaler) or >400 mcg/day (HFA)
Use for step 5 or 6
ICS Class side effects
Oral candidiasis (rinse mouth after use)
Hoarseness
May slow bone growth in children (but similar adult height)
Arnuity (fluticasone furoate) is contraindicated with severe hypersensitivity to milk protein
ICS onset of improvement
5-7 days
SAMA class side effects
Headache
skin flushing
blurred vision
tachycardia
palpitations
Spiriva Respimat unique indication
Only LAMA indicated for long term maintenance asthma treatment >=12 y/o
Albuterol side effects
tremor
tachycardia (less w/ levalbuterol)
hypokalemia
hypomagnesemia
hyperglycemia
tachyphylaxis
SABA/SAMA combination primary use
used primarily in COPD
LAMA/LABA combination use
maintenance of COPD
glycopyrrolate/formoterol (Bevespi)
tiotropium/olodaterol (stiolto)
umeclidinium/vilanterol (anoro)
aclidinium/formoterol (duaklir)
Single Maintenance and Reliever Therapy (SMART)
budesonide/formoterol (symbicort)
5-11: 1-2 puffs prn up to total daily maintenance and reliever dose of 8 puffs/day
> =12: 1-2 puffs prn up to a total daily maintenance and reliever dose of 12 puffs/day
ICS + LABA dosing frequency
All are 2 puffs BID.
Exceptions:
-fluticasone/salmeterol DPI (advair diskus) = 1 puff BID
-Fluticasone furoate/vilanterol (breo) = 1 inh once daily
Leukotriene Receptor Antagonists
Montelukast, Zafirlukast, Zileuton
ADR: HA, GI upset, heptatoxicity (Zs only)
BBW (montelukast only): neuropsychiatric events
Montelukast can be used as young as >=1y/o. Zileuton can only be used in >12 y/o.
Inx with warfarn, theophylline (Zs only)
Used as alternative therapy in Steps 2-5
Step 4 & 5 must also include ICS
Omalizumab (Xolair)
IgE-binding inhibitor MAB given every 2-4 weeks as >= 6 y/o
Second line therapy for severe persistent allergy-related asthma
Increased risk of CV and cerebrovascular ADRs (MI, TIA, PE/DVT, unstable angina, pulmonary HTN)
Can be self-injected
Dupilumab (dupixent)
IL-4 antagonist SC every other week >=6/yo
Add-on therapy with eosinophilic asthma or OCS-dependent
Do not give live vaccines
IL-5 antagonists
mepolizumab (nucala) - SC q4w >=6y/o
reslizumab (cinqair) - IV q4w >=18 y/o
benralizumab (fasenra)- SC q4w x3 doses then q8w >=12 y/o
Must try for 4 months to determine efficacy
Add on maintenance therapy for severe asthma with eosinophilic phenotype
Tezepelumab (Tezspire)
Thymic stromal lymphopoietin (TSLP) blocker
Given SC q4w
We never have on hand
Add on maintenance for >=12 y/o
At least 4 months needed to determine efficacy
Breathing technique for inhalers
Slow & Deep:
HFAs
Ellipta (anoro, breo, arnuity, incruse)
Respimat (combivent, spiriva, striverdi, stiolto)
Steady & deep, not too forceful:
Spiriva handihaler
Quick, forceful, deep:
Multidose DPIs (pressair, twisthaler, flexhaler, diskus)
Respiclick
Digihaler
Exercised-induced bronchospasm
Diagnosis: Exercise challenge. FEV1 decreases by 15%, or peak expiratory flow occurs before and after exercise, measured at 5 min intervals for 20-30 min
Treatment: can initiate or step up, especially if frequent/severe
Pretreatment with SABA or low-dose ICS-formoterol and prn for symptom relief is recommended
Can use LTRAs but onset is hours after administration
When to assess with spirometry
Baseline
After treatment started and symptoms stable (3-6 mo)
If prolonged or progressive loss of asthma control
Then at least every 2 years
Only >=5 y/o
Asthma Action Plan - Green
No/minimal symptoms of coughing, wheezing, dyspnea
Continue maintenance, reliever inhaler, avoid triggers
Asthma Action Plan - Yellow
Increased frequency of symptoms, nighttime awakenings. Decreased ability to do normal activities
peak expiratory flow rate (PEFR) 50-79%
Plan:
1) Increase reliever to max of 72mcg formoterol/day or SABA 2-4 puffs, repeat in 20 min
2) Wait 1 hour.
—Complete response: contact physician, consider steroid burst
—Incomplete response: repeat SABA. Add steroid burst.
—Poor response: repeat SABA immediately. Add steroid burst. Contact physician immediately or go to ER.
3) Continue SAVA q3-4 hours regularly for 24-48 hours
Steroid burst for asthma exacerbation using asthma action plan
prednisone
Adults: 40-60mg/day for 5-7 days
Children: 1-2mg/kg/day x3-5 days
Asthma Action Plan - Red
Medical alert- inability to speak more than short phrases. Use of accessory respiratory muscles. drowsy.
PEFR <50% best
Plan:
1) Contact physician immediately
2) Increase reliever. Max formoterol 72mcg/day. SABA 2-6 puffs
3) If incomplete/poor response, repeat SABA immediately, go to ER if severe distress
4) If lips/fingernails blue or gray, trouble walking or talking b/c of SOB: go to ER
Continue SABA q3-4h for 24-48h
Mild or moderate asthma exacerbation
S/S:
-Talk in phrases
-Sitting > lying
-RR, HR increased; O2 on RA 90-95%
PEF >50% of personal best
Treatment:
-Treat at home or office visit
-Oxygen if needed
-SABA +/- oral steroids
Severe asthma exacerbation
S/S:
-dypsnea at rest
-Interferes with conversation
-sits hunched forward
-HR >120, RR >30, accessory muscles, O2 RA <90%
PEF<=50% best
Treatment:
-ED visit, hospitalization
-Oxygen
-PO steroids
-High dose SABA + ipratropium
Life-threatening asthma exacerbation
S/S:
-Too dyspneic to speak
-Perspiring
-Confused, drowsy
PEF <25% best
Treatment:
-ER, possible ICU
-Little or no relief from SABAs
-IV steroids
SABA dose during mild-severe exacerbation
Albuterol 4-10 puffs q20 minutes up to 4 hours, then every 1-4 hours as needed
OR
nebulizer* q20 min for 3 doses then q1-4hours prn
*should include ipratropium for severe
Steroid burst for mild-severe asthma exacerbation requiring treatment
prednisone
adults: 40-50mg 1-2x daily
peds: 1-2mg/kg in two divided doses (max 40mg/day)
Give until peak expiratory flow >70%
Adjunctive therapies for severe-life-threatening asthma exacerbation
IV magnesium
IV ketamine
Heliox
Consider if patient unresponsive
Respiratory arrest plan from asthma exacerbation
Mechanical ventilation w/ oxygen 100%
Nebulized SABA + ipratropium
IV steroids
IV Magnesium or heliox if unresponsive to therapy
Gold standard diagnosis for COPD
Spirometry
FEV1/FVC <70%
GOLD 1
Mild FEV >=80%
GOLD 2
Moderate FEV 50-79%
GOLD 3
Severe FEV 30-49%
Gold 4
FEV <30%
COPD Group A
CAT <10, mMRC 0-1
No hospitalizations
<=1 exac in past year
Initial: Bronchodilator (short or long-acting)
COPD Group B
CAT >=10, mMRC >=2
No hospitalizations
<=1 exac in past year
Initial: LABA + LAMA
COPD Group E
Few or many symptoms
>=1 COPD-related hospitalization OR
>=2 exac in past year
LABA + LAMA
or
LABA + LAMA + ICs (esp. if eosinophils >300)
COPD Therapy Modification if on LABA or LAMA, with predominant dyspnea
Change to LABA + LAMA
May also need to change inhaler device
May need to investigate other causes dyspnea
COPD Therapy Modification if on LABA + LAMA, with predominant dyspnea
Change inhaler device
Escalate nonpharm treatment
Treat other causes of dyspnea
COPD Therapy Management if on LABA or LAMA, with predominant exacerbation
LABA + LAMA
or
LABA + LAMA + ICS (eosinophils >300)
COPD Therapy Management if on LABA + LAMA, with predominant exacerbation
LABA + LAMA + ICS (if eosinophils >300)
or
If eosinophils <100, add roflumilast (also FEV <50% and chronic bronchitis)
AND/OR azithromycin daily (if former smoker)
COPD Therapy Modification if on LABA + LAMA + ICS, with predominant exacerbation
De-escalate ICS and change to LABA + LAMA
or
Add roflumilast if FEV <50% and chronic bronchitis
AND/OR azithromycin daily (if former smoker)
Roflumilast (Daliresp)
PDE-4 inhibitor
Indication: daily treatment to reduce risk of COPD exacerbations. Inhibits breakdown of cAMP – no direct bronchodilator activity
Must have FEV <50%, chronic bronchitis, history of frequent exac despite being on LABA + LAMA + ICS, especially if eosinophils <100
Contraindicated in liver impairment and breastfeeding
Azithromycin in COPD
Anti-inflammatory and antibacterial properties
Add-on therapy for LABA + LAMA +/- ICS if eosinphil <100 and former smoker
250mg daily or 500mg 3x/w
Home oxygen therapy
Recommend if Pao2 <55mmHg or Sao2 <88% with or without hypercapnia, confirmed twice during 3-week period
Improved survival with long term use
BB in COPD
Not recommended for COPD, but do not withhold in patients with heart disease
Possible benefit due to upregulation of B2 receptors on lungs, thus making bronchodilators more efficient
Statins in COPD
Possible benefit in reducing exacerbations and COPD mortality
Not recommended to initiate in COPD if no other cardiac risk factors
Preferred treatment of COPD exacerbation
SABA w or without ipratropium
Steroids in COPDe
-Effective
-Shorten recovery time
-Improve FEV1
-Improve/shorten hospital stays
Use in most exacerbations (not needed in mild)
Outpatient: prednisone 40mg daily x5 days (noninferior to 14 days)
Most common pathogens for COPDe
S. pneumoniae
H. influenzae
M. catarrhalis
Pseudomonas if GOLD 3-4
Cardinal symptoms of COPDe
Increased dyspnea
Increased sputum volume
Increased sputum purulence
Antibiotics for COPDe
Give if all 3 cardinal symptoms present OR
2/3 present with 1 being increased purulence
OR
if requiring intubation
Empiric: Augmentin, Azithromycin, Doxycycline
ABX in past 3 months: Use alternative class
Consider Augmentin or levo/moxi if complicated COPD w/ risk factors (comorbid dx, FEV <50%, >3 exac/year, ABX in past 3 mo)
GOLD 3-4: levo 750 or cipro + sputum culture
5-7 days
Adult with previous PPSV23 vaccine
Give PCV20 or PCV15 (at least 1 yr after PPSV23), no need for additional PPSV23 after PCV15.
Adult with previous PCV13, have not completed PPSV23
PCV20 one year after PCV13 or complete PPSV23 series
RSV Vaccine for pregnancy
Abrysvo
32-36w
Flu vaccine without egg
Recombinant influenza vaccine (RIV)
cell culture based inactivated vaccine (ccIIV4)
Tdap if patient has recent Td
Tdap recommended as one-time replacement for Td, including 65 and older
LAMA benefits in COPD
-delays first exacerbation
-reduces overall # COPDe & hospitalizations
-Improves symptoms, health status
-Improves pulmonary rehabilitation
No significant FEV1 improvement
LABA vs LAMA COPD
Tiotropium > Salmeterol in time to first exac & annaul # of exac
TIoptropium > LABA at preventing exac but NOT in overall hospitalization/mortality
LABA/LAMA > LABA/ICS in preventing copd exac
LABA benefits COPD
-improve health status
-improve QOL & FEV1
-Decreased COPD exac rate
No effect on mortality or rate of lung function decline
Salmeterol significant reduces hospitalization rate & treatment of exac
ICS monotherapy in COPD
AVOID
Can increase mortality compared to combination therapy
