Q3 Pulm Flashcards
First line for asthma tx
ICS - Beclomethasone, budesonide, fluticasone, mometasone
- with rescue SABA/LABA - albuterol, levalbuterol/salmeterol, formoterol.
What therapy is useful for nocturnal symptoms of asthma?
LABAs - salmeterol and formoterol.
How do SABAs/LABAs work?
Beta2 agonists that relax the airway smooth muscle by stimulating beta 2 receptors in the airway.
Since SABAs are not 100% selective, what other things do they affect?
Can affect cardiac and skeletal muscle B1 receptors. = tachycardia, muscle tremors.
What medications can be used Off Label for asthma? MOA?
Anti Cholinergic - although mostly used in COPD.
Ipatropium (SAMA) and Tiotropium (LAMA)
MOA - inhibit Muscarinic acetylcholine receptors in the lungs to inhibit bronchoconstriction.
What LTRA is used in asthma and what is its MOA?
Leukotrienes receptor antagonist (LTRA) - anti inflammatory
Monteleukast.
What is theophylline and is it used in asthma?
Methylxantine - anti-inflammatory properties and bronchodilator by relaxing smooth muscle in lungs
Not typically used in asthma - ICS are better.
What meds are reserved for treatment resistant asthma?
Immunomodulators (monoclonal antibodies)
Omalizumab and Mepolizumab and reslizumab.
SABA/LABA onset and duration
SABA - 30min/ 3-5hrs
LABA - 30-60min/>12hrs
LABAs are best combined with _____
ICS
What is the agent of choice for long term asthma therapy? Clinical considerations?
ICS.
Educate patient to rinse mouth out with water after use (to prevent oral thrush)
Oral steroids should be used ______
Short term - <2weeks
Step 1 reliever and controller
Step 2
Step 3
Step 4
Step 5
Step 1 = PRN ICS - formoterol and PRN SABA
Step 2 = Daily low dose ICS or PRN low dose ICS - formoterol OR daily LTRA and low dose ICS whenever SABA is taken + PRN SABA
Step 3 = daily low dose ICS-LABA or medium dose ICS + PRN SABA
Step 4 = Daily Medium dose ICS-LABA or high dose ICS and add-on tiotropium or LTRA + PRN SABA
Step 5 = daily high dose ICS-LABA, refer for phenotypic assessment, and add on therapies, Low dose OCS but consider SEs + PRN SABA
Class A, B, C, D for COPD
A = low symptom burden (mMRC 0-1, CAT <10) and low airflow limitation (grade 1-2 GOLD)
B = high symptom burden (mMRC >=2, CAT >=10) and low airflow limitation (grade 1-2 GOLD)
C = low symptoms burden, high airflow limitation (3-4GOLD)
D = high symptom burden, high airflow limitation
Class C COPD tx?
Class A?
B?
D?
C = LAMA
A = ??
B = ??
D = LAMA or LAMA+LABA (if highly symptomatic CAT>20) or ICS+LABA (eosinophils>=300).
When should corticosteroids be added in COPD therapy?
In FEV1<60%
Therapy for COPD:
Bronchodilators: B2 agonists (S+L), Anticholinergics (S+L), Methylxanthines.
Corticosteroids
Other clinical considerations for COPDers?
Flu vaccine yearly, PPSV23 vaccine x1 to all COPD patients. If over 65, then repeat if it’s been >5 years
PCV13 EVERYONE over 65
Hh
Free form drawings
A LABA should be added when?
When a patient is not maintained with ICS
SABAs should not be overused because?
decrease efficiency over time.
MOA of Leukotrienes receptors?
Leukotrienes are chemicals released when exposed to an allergen. If they receptors are blocked, then they can’t mount as intense an immune response.
T/F: bronchodilator’s should not be used to treat COPD because COPDers do not have an “adequate response” to them (<80%)
False. The can still improve symptoms and improve activity tolerance.
Meds used in tx of COPD
Bronchodilators
- beta 2 agonists (SABA and LABA)
- Anticholinergics (LAMA/SAMA)
- corticosteroids.
Duration of therapy for pneumonias:
T/F: if a CAP patient is a febrile for 48-72hours and stable, treatment may be discontinued before the 5 days.
CAP at least 5 days.
HAP and VAP 7 days
True
What is the duration of Azithromycin PO 500mg for CAP?
3 days - it has a long half life and can remain in the body past those 3 days.
What is the new flu medication?MOA?
Baloxavir Marboxil (Xofluza)
Endonuclease inhibitor.
When you have aspiration PNA, there is concern for ______ bacteria. Treat with ______
Anaerobic
Metronidazole + PCN or amoxicillin or ampicillin/sulbactam.
What are Paxlovid, Molnupravir and Remdesivir MOA?
Viral replication blockers. Use to tx COVID.
You are treating a child for AOM with Penicillin G but they are not improving. What might the pathogen be? What would be a better antibiotic?
PRSP - penicillin resistant strep pneumoniae.
Amoxicillin - 1st line DOC in AOM.
1st line DOC in AOM?
Amoxicillin.
Most prevalent bacteria in AOM?
S. Pneumoniae.
If the patient has received amoxicillin the the past 30days or hx of recurrent AOM, try _______
If patient is allergic to PCN_____
Amoxicillin/clavulanate
Anaphylaxis: consider Macrolide or clindamycin
Non-anaphylaxis: cephalosporin
The younger the patient the ______ the course for AOM.
Longer
Ibuprofen should be avoided in children <_____
6mo
DOC for pharyngitis? Alternatives? Allergy to PCN?
Duration of course?
Penicillin
Amox or Cephalosporins.
Azithromycin or clindamycin
5-10 days
What are some patient education facts about intra nasal ipratropium (class?)
Anticholinergic
Only use with rhinorrhea - doesn’t improve congestion post nasal drip or sneezing. Can potentially cause nose bleeds and dry mouth.
Limit intra nasal decongestants to _____ to prevent _______
3-5 days
Rebound congestion.
Oral decongestants are CI in _____
CV, DM, hyperthyroid
read book “KEY CONCEPTS” for TB, CF, ARDS meds
Typical tx regimen for CF patient
Albuterol for bronchospasm
Mucolytic agent (Doran’s Alfa, Hypertonic saline)
Inhaled antibiotics (Azithromycin)
PERT
Vit DEAK
Ursodiol (prevent liver disease)
Insulin if pancreatic insufficiency
And a precision therapy CTFR potentiators/agonist (Ivacaftor, Orkambi, Symdeko and Trikafta)
What is the MOA of Dornase Alfa? (Mycolytic agent)
\
Recombinant human DNase that selectively cleaves extracellular DNA released during neutrophil degradation in viscous CF sputum.
When might Hypertonic saline nasal spray be contraindicated in CF patients?
It can cause bronchospasm, so it must be administered together with a bronchodilator, and some patients do not tolerate it.
How can high dose ibuprofen benefit CF patients?
MOA: inhibits lipoxygegnase pathway to reduce neutrophil migration and reduce release of lysosomal enzymes.
20-30mg/kg BID.
Treatment for AXTIVE TB = ______
RIPE
Rifampin x6mo
Isoniazid x 6mo
Pyrazinamide for 2 mo
Ethambutol for 2 mo
A patient is at high risk for failure of TB tx if they:
Have cavitary lesions or have positive AFB culture after 2mo of therapy.
Treatment of LATENT TB
Mono therapy
Isoniazid for 9mo
OR
Rifampin x4 mo
Treating LTBI decreases lifetime risk of developing active TB from _____ to_____
10% to 1%
Rifampin SEs
CI?
Orange discoloration of body fluids
GI issues,
Severe immune rxn
CI with anti-xa inhibitor anticoagulants.
Isoniazid SEs?
Hepatitis, peripheral neuropathy, monoamine poisoning.
Pyrazinamide SEs
Hepatotoxic, GI, no gout poly arthritis, rash, hyperuricemia.
Ethambutol SEs and clinical considerations?
Retrobulbar neuritis and peripheral neuritis
Baseline and monthly visual acuity.
What can minimize effects of peripheral neuropathy when on isoniazid tx?
Daily Pyridoxine (or Vit-B6)
Rifampin MOA
Inhibits bacterial DNA-dependent RNA polymerase by binding to the subunit and blocks the elongating of the RNA. Bacteria is unable to reproduce.
MOA for isoniazid
Inhibit bacteria cell wall synthesis after being activated by the MTB enzyme KatG catalase.
MOA for Pyrazinamide
Disrupt MTB membrane transport and energetic by Pyrazinoic acid
T/F: the treatment of choice for NON-hemorrhagic hypovolemia is colloid-containing solutions.
FALSE>
Crystal Lodi solutions (LR, NS or Plasma-Lyte)
When would someone with Non-Hemorrhagic hypovolemia need blood products?
If their corrected Hgb was <7
What is the sodium, chloride concentration and osmolarity of plasma?
Na/Cl concentration and osmolarity of NS?
LR?
PlasmaLyte?
Plasma = Na 135-145, Cl 94-111, Osm 275-295
NS = Na 154, Cl 154, Osm 308
LR = Na 130, Cl 109, Osm 273
Plasma-Lyte = Na 140, Cl 98, Osm 294.
Since NS has a _____ Na, ____ Cl and a ______ Osm than plasma, it would create what in the body if too much was infused?
Anyone receiving > _____L of NS is at risk.
More Na
More Cl
Higher Osm
It is HYPERTONIC - it would draw water out of the cells and tissue, and put too many negative ions in circulation causing hyperchloremic metabolic ACIDOSIS.
> 3L
The comparison “ Robbing Peter to pay Paul “ can be used in what scenario?
Use of Colloid containing solutions in hypovolemia or patients who are 3rd spacing.
you boost intravascular volume, but starve the tissue.
Why should colloids NOT be used in hemorrhagic patients?
It may boost the intravascular volume and BP TOO much and “pop the clot”
When is albumin good to consider?
If stable patient is low albumin (liver failure)
The rate of fluid replacement in hemorrhagic shock and hypovolemia should be _______
Individualized
Weight based
Rate of fluid replacement in hypovolemia:
30ml/kg completed by 3 hours following presentation. (same as sepsis)
Patient presents to ER with severe hypovolemia. They weigh 86kg. Fluids started at 1900. How much should be infused by 2200?
30ml/kg = 2,580ml in 3 hrs = 860ml/hr.
