Respiratory Flashcards
ASTHMA PATHO
chronic INFLAMMATORY disorder of airways
symptoms at night or in early morning
REVERSIBLE airway obstruction
INC responsiveness to stimuli
**each acute exacerbation causes structural remodeling of airways = thickening of bronchial/bronchiolar mucosa, submucosa, and smooth muscle layers
ASTHMA drug therapy
Beta 2 agonists
glucocorticoids
leukotriene modifiers
methylxanthines
anticholinergics
anti-IgE treatment
COPD drug therapy
choice of therapy dependent on:
1) availability of med
2) patient’s response
Inhaled therapy (preferred method)
anticholinergics
B2 agonists
glucocorticoids
other routes:
methylxanthines
phosphodiesterase-4 inhibitors
GOLD guidelines
GROUP A (MILD): bronchodilator
GROUP B: LAMA/LABA (if persists, combine both)
GROUP C: INC exacerbations = LAMA + (LABA or ICS)
GROUP D (VERY SEVERE): LAMA + (LABA + ICS + additional) (pulmonology referral)
BETA 2 Agonists MOA
stimulate B2 receptors in the airways
bronchodilation, smooth muscle relaxation, mast-cell membrane stabilization
BETA 2 Agonists Adverse effects
INC HR
Shakiness
Arrhythmias
Restlessness
Tremors
Dizziness
HA
BETA 2 Agonists Contraindications/Special considerations
ASTHMA: acute attacks
SABA = rescue
LABA = maintenance/control
COPD: subjective improvement; quality of life
SABA = acute exacerbations
LABA = sustained bronchodilation, more convenient dosing, no rescue use
BETA 2 Agonist Interactions
most common:
digoxin
tricyclic antidepressants (TCA)
MAOI
BB
BETA 2 Agonists Patient education
Meter-dosed inhaled forms use spacer = Children
PREGNANCY: terbutaline safe; albuterol best SABA; ICS for long-term control
Glucocorticoids medications
Inhaled:
beclomethasone MDI
budesonide MDI
flunisolide MDI
fluticasone MDI
mometasone - adult only
triamcinolone MDI
Systemic: PO
oral - prednisone and methylprednisolone
parenteral - methylprednisolone and dexamethasone
Glucocorticoids MOA
inhibit synthesis and release of inflammatory mediators
INC number and responsiveness of B2 receptors (improve lung function when combined w/ LABA in COPD)
DEC mucous production and hypersecretion
Glucocorticoids ASTHMA
Inhaled are preferred controller tx
step 2 preferred tx
systemic are used only for hard to control asthma; if introduced early in acute attacks can help to reverse inflammation and speed recovery
Glucocorticoids COPD
ICS
FEV1 <50% predicated and repeated exacerbations
reversible factors = acute inflammation d/t viral infection and pollutions
scarring and chronic inflammation in COPD are NOT reversible
only thing that helps stop the decline of FEV1 is to STOP SMOKING
Glucocorticoids Adverse effects
inhaled - oropharyngeal candidiasis and dysphonia
systemic - HPA axis suppression, growth retardation, DEC bone mineral density, hyperglycemia, steroid myopathy, weaken blood vessels, DEC skin thickness
Glucocorticoids Contraindications/Special considerations
Contraindications:
acute attacks
children, especially PO form
Interactions: Azoles
Glucocorticoids Patient education
rinse mouth after using inhaler
Leukotriene modifiers MOA
ALLERGY MANAGEMENT
inhibit action of leukotrienes
smooth muscle contractions, DEC inflammation, edema, mucus secretions
INC bronchodilation
Leukotriene modifiers medications
montelukast (singulair)
zafirlukast (accolate)
zileuton (zyflo)
Leukotriene modifiers ASTHMA
NO ACUTE ATTACKS
alternative tx in asthma
ADD to steps 3-4
Leukotriene modifiers COPD
NO ROLE IN TX
Leukotriene modifiers Adverse effects
HA
GI upset
Resp infections (older adults)
Leukotriene modifiers Contraindications/Special considerations
No inhaled, PO meds only
Leukotriene modifiers Patient education
montelukast - once daily, BEST in evening
zafirlukast - BEST on empty stomach
Zileuton - no regards to meals
Methylxanthines MOA
DEC mast cell mediator release
bronchodilation, enhance mucociliary clearance, INC contraction of fatigued diaphragm
Methylxanthines DOC
Theophylline
Methylxanthines ASTHMA
STEP 3-5
NOT for monotherapy
Methylxanthines COPD
mild bronchodilator
3rd line agent d/t NARROW TI
Methylxanthines Adverse effects
CNS, GI, CV
uncommon serum level below 20
see ADEs serum level 15-20
Methylxanthines Contraindications/Special considerations
Contraindications:
NO PREGNANCY - cross placenta
sensitivity to caffeine, xanthine
seizure disorders
PUD
Interactions: metabolized by CYP450
Methylxanthines Patient education
1) dosed by patient’s weight and serum level
2) NARROW TI = serum monitoring
3) risk of toxicity
Caffeine is methylxanthine
report sx
take med exactly as prescribed
Anticholinergics MOA
inhibit cholinergic receptors
inhibit parasympathetic action
produces bronchodilation, DEC mucous secretions
Anticholinergic meds
Ipratropium (atrovent) MDI = COPD
Tiopropium (spiriva) MDI = ONLY COPD
Anticholinergic ASTHMA
alternative to SABA
NO chronic asthma
ACUTE ATTACKS
Anticholinergic COPD
ALL STAGES COPD
Add to SABA in acute COPD
Anticholinergics Adverse effects
CAN’T SEE, PEE, SHIT, SPIT
restlessness
dizziness
HA
GI distress
blurred vision
palpitations
urinary obstruction
Anticholinergics Contraindications/Special considerations
contraindications:
hypersensitivity to ATROPINE, acute bronchospasm
Caution: narrow-angle glaucoma, BPH, Pregnancy, lactation
Anticholinergics Patient education
MDI and neb forms
when inhaled, confined to mouth/airways
Anti-IgE treatment meds
Omalizumab (xolair) injectable
Anti-IgE treatment ASTHMA
STEP 5
IgE >30
allergic asthma if uncontrolled on standard tx
mod-sev asthma = ICS not effective
Anti-IgE treatment Adverse effects
HA
injection site reaction
upper resp tract infection
Anti-IgE treatment Contraindications/special considerations
NOT for acute asthma attacks
Anti-IgE treatment Patient education
PREGNANCY SAFE
BLACK BOX: anaphylaxis
monitor for sx and improvement in QOL, use of rescue meds, Not serum IgE
dosed every 2-4 wks by body weight
dose/dose frequency are determined by pre-treatment IgE levels
Allergic Conjunctivitis
DOC: ophthalmic H1 blocker Ketotifen
adults and children >3
dose: 1 drop in affected eye Q8-12 hours
OTC products: combine decongestant and antihistamine
COPD PATHO
chronic bronchitis/emphysema
disease state characterized by airflow limitation that is NOT FULLY REVERSIBLE
usually progressive
associated w/ an abnormal inflammatory response of the lungs to noxious particles of gas
INC exacerbations = DEC baseline
COPD Diagnostic criteria
determined by spirometry tests of lung function
positive diagnosis made when the ratio of FEV <70%
COPD Stages
1) At risk (smokers, exposed to smoke, cough, dyspnea, sputum, family hx) = FEV1 >0.7 FEV1 > 80% of predicted
2) Mild = FEV1 <0.7; >80% of predicted
3) Moderate = FEV1 <0.7; 50% <FEV1 <80% of predicted
4) Severe = FEV1 <0.7; 30% < FEV1 < 50% of predicted
5) Very Severe = FEV1 <0.7; <30% of predicted, or FEV1 <50% of predicted plus chronic resp failure
COPD Goals of therapy
1) address symptoms and quality of life
2) health education
3) pharmcotherapy
COPD Patient education
1) smoking cessation
2) patho COPD understanding
3) medication skills
4) specific drug therapy
5) reasons for drugs being taken
6) drugs as part of the total treatment regimen
7) adherence issues
COPD Vaccines
Influenza vaccine - annually; earlier the better
pneumococcal vaccine - every 6 years
Smoking Cessation: Questions to ask
1) is patient ready to quit smoking?
Smoking cessation: Nicotine
adjunct to smoking cessation program
MOA: vasoconstrictor
SE:
CNS: peripheral vasoconstriction, tachycardia, HA, paresthesia, fatigue, insomnia, nausea, hot flashes, **nightmares
GI: N/V/D, dry mouth, dyspepsia
Nasal spray: irritation, cough, sneezing
Patch: skin irritation, burning
CONTRAINDICATIONS:
NO PREGNANCY - cross placenta
NO LACTATION - in breast milk
**NOT used immediately after MI, those w/ arrhythmias, severe angina
MED admin: patch
21 mg >or= 1 ppd
14 mg = 1/2 ppd
Patient education:
1) AVOID smoking = overdose or toxicity
2) Be aware sleep disturbances
3) Inspect oral cavity = using gum
4) teach to use system correctly
Smoking Cessation: Bupropion
Zyban (brand)
Wellbutrin - antidepressant
SE:
INC HR
HA
insomnia
dizziness
xerostomia
weight loss
nausea
pharyngitis
Contraindications: seizure disorders, eating disorders, MAOI use
Med admin:
1) dose 150mg/day x3 days, then BID
2) suggested use 12 wks
3) start 1 wk before quit date
4) DEC seizure threshold
5) INC libido
Patient education:
1)BLACK BOX: suicidal thinking
2) AVOID ETOH = INC depression
3) can combo w/ nicotine patches = BETTER
4) report resp difficulties, unusual cough, dizziness, or muscle tremors
Smoking Cessation: Varenicline
Chantix (brand)
MOA: partial agonist w/ high affinity and selectivity for alpha4-beta2 nicotine acetylcholine receptor
SE: insomnia, HA, abnormal dreams
Precautions:
NO PREGNANCY
NO LACTATION
pre-existing psych disorders
NO children <18
Med admin:
1) 12 wk intervention program
2) dose adjustment for RENAL impairment
3) complete patient education program
4) start 1 wk before quit date
5) can DEC dose if experiencing ADEs
Patient education:
**Neuropsych sx reported w/ use and withdrawal of med = INC anger
give w/ food and water to DEC GI effects
Why is it hard for smokers to quit?
nicotine addition
not ready to quit
Respiratory ALLERGIES
antihistamines 1st GEN: benadryl
ADE: drowsiness
adult dose: 25-50 mg Q4-6 hours
IF patient cannot TOLERATE 1st Gen = 2nd GEN can be given
cetirizine
(children >12) = 5-10 mg/day daily
children 6-11 = 5-10 mg once daily
renal impairment = fexofenadine 60 mg once daily
renal/liver disease = loratadine 10mg every other day
renal/liver impairment = desloratadine given every other day
When to use ORAL (eye/nasal) drugs
When to use TOPICAL (eye/nasal) drugs
COUGH: med types
antitussive
expectorant
COUGH: Antitussives
dextromethorphan (DM)
codeine
benzonatate
COUGH: Expectorants
guaifenesin
ANTITUSSIVE: Dextromethorphan
INDICATION: dry, hacking, non-productive cough
works directly on cough center in medulla
chemically related to opiates
rapidly absorbed from GI
INTERACTIONS: CNS depressants, MAOI, fluoxetine, quinidine, sibutramine, ETOH
adolescent abuse; can overdose
Pregnancy: CAUTION near term
AE rare: N/V, irritability, serious drowsiness, dizziness
administer evenly spaced intervals
equally as effective as codeine
ALCOHOL/SUGAR content: CAUTION in DM, ETOH, taking FLAGYL
ANTITUSSIVE: Codeine-scheduled drug
Works directly on cough center
Drying effect on mucous and can INC viscosity of secretions
metabolized by liver P-450
PREGNANCY - crosses placenta
NO LACTATION - enters breast milk
CONTRAINDICATIONS: other narcotics, those who NEED productive cough
abuse potential
CAUTION in children and elderly
AE: drowsiness, sedation, dry mouth, N/V, constipation
respiratory depression in HIGH doses
Interactions: antihistamines, barbiturates, histamine 2 blockers, phenothiazines
EDUCATION: measure correctly, do NOT share, warn about sedation
ANTITUSSIVE: Benzonatate
tessalon perles - gel capsule
Non-narcotic
anesthetizes stretch receptors in resp tract to DEC cough reflex
no known interactions
PREGNANCY: caution, only if clearly indicated
NO LACTATION
NO CNS depression
adults and children >10
must swallow whole
AE: drowsiness, HA, dizziness, GI upset, pruritus, skin eruptions
EXPECTORANT: Guaifenesin
robitussin
mucinex
Non-productive dry cough
MOA: enhances output of resp tract fluids; DEC stickiness and surface tension of fluids
THINS MUCUS
onset 30 mins
no drug interactions
PREGNANCY; CAUTION
may use in children >6
NO ETOH
AE: N/V, anorexia, HA, dizziness
take w/ full glass of water
COUGH meds warnings
1) active ingredients are often mixed cough suppressant and expectorant
2) cancel each other out
3) patient may be taking multiple products w/ same active ingredients
4) WATCH acetaminophen and ETOH levels
5) NEVER use more than 3-7days
6) NOT recommended for children <6
Antihistamines CONTRAINDICATIONS/PRECAUTIONS
CONTRAINDICATIONS: narrow angle glaucoma
LRI
PUD
BPH
MAOI
CAUTION:
urinary retention
asthma
hyperthyroidism
CV
HTN
ANTICHOLINERGIC EFFECTS
Antihistamines 1st Gen MOA/USES
H1 receptor blockers: blocks action of histamine released during inflammatory response
restores normal airflow to the upper resp system
ALLERGIC RHINITIS
Antihistamines 1st Gen DOC
Diphenhydramine (benadryl)
IM, IV, PO forms
indicated: allergic disorders where PO form is impractical or contraindicated
adjunct in anaphylaxis
allergic rxn to blood/plasma products
NOT recommended in neonates, premature infants, ACUTE ASTHMA
Antihistamines 1st Gen what to know
oldest
sedating (cross BBB) = drowsiness
NO LACTATION = dry breast milk
NO children <6
can cause CNS stimulation (HYPER) in children
Interactions: MAOI, CNS depressants, TCAs, antimuscarinics
PREGNANCY SAFE
Antihistamines 2nd Gen MOA/USES
seasonal and perennial allergic rhinitis
allergic conjunctivitis
urticaria
angioedema
**most effective before onset of sx (seasonal and perennial allergic rhinitis)
Antihistamines 2nd Gen Meds
cetirizine (zyrtec)
fexofenadine (allegra)
loratadine (claritin)
desloratadine (clarinex)
Antihistamines 2nd Gen what to know
longer acting
less sedating (no cross BBB)
enters breastmilk = NO LACTATION
do NOT given w/ CNS depressants, other H1 blockers, macrolides (torsades)
CAUTION: certain antibiotics, antifungals, children <6
give w/ or w/o food
**most effective before onset of sx (seasonal and perennial allergic rhinitis)
Antihistamines INHALED
SEASONAL ALLERGIC RHINIITS AND VASOMOTOR RHINITIS
H1 blocker and inhibitor from mast cells
may interfere w/ histamine and leukotriene induced bronchospasm
SE: epistaxis, throat irritation, BAD taste
Decongestants
phenylephrine
pseudoephedrine
DEC nasal congestion = opening
ALPHA ADRENERGIC AGONISTS
constrict nasal arterioles = DEC nasal swelling
may constrict GI/GU sphincters
HIGH abuse potential
Pregnancy C
Caution in children <12
contraindications: MAOI, BB, TCA
NO patient w/ HTN, CAD
AE: CNS related anxiety, restlessness, tremors, insomnia, convulsions, hallucinations
CV effects: INC BP, tachycardia, arrhythmias
extreme dryness of mucus membranes
PO no longer than 4 days use; topical 48-72 hours = risk rebound congestion
NASAL Steroids
beclomethasone
ALLERGIC RHINITIS
work better than PO antihistamines
minimal systemic effects and AEs
long term or high dose may cause systemic reaction
ADEs: burning, itching, drying sensation
Dose on regular or PRN schedule
Inhaled Mast Cell Stabilizer
intranasal Cromolyn sodium
shields mast cells lining nasal passage and prevents histamine release
use 4-6 xday
PREGNANCY SAFE
Inhaled Anticholinergic Agents
intranasal Ipratropium bromide
DEC watery nasal secretions in upper resp passages
No significant relief for other sx
adults and children >6
pregnancy B
NO IF ALLERGY TO ATROPINE
AE: epistaxis, pharyngitis, nasal dryness or irritation
Non-pharmacological decongestant therapies
nasal strips - hold open nasal passage
vapor inhaler - vasoconstrictor; will cause HTN, tachycardia
adults and children >2
no more than 7 days
