Respiratory - Asthma & COPD Flashcards
Describe how asthma –> airway remodeling
Asthma trigger
–> inflammation and acute broncho cxn
–> neutrophil and eosinophil infiltration
–> basement membrane thickening and goblet cell
proliferation
Why is wheezing not a good measure of asthma exacerbation?
B/C absence of wheezing can either me resolution of the issue or complete closure of the airways
What are the two main goals of asthma management?
1) Open airway and ease breathing
2) Prevent or limit inflammation
What is the primary difference asthma and COPD?
- the reversibility of the changes occurring with each exacerbation
1) What does spirometry measure?
2) What pulmonary function definition does spirometry correlate to?
1) volume and force of air expired
2) forced vital capacity (FVC)
1) Why is spirometry a diagnostic measure of asthma?
2) What is the purpose of doing a pre and post bronchodilator?
1) Because it measures degree of severity
2) Evaluate the degree of reversibility
How would you instruct a patient to use a spirometer?
- Take a full breath in
- Then blow out your full breath as fast as you can
May need 2-3 practice trials
↑↓ ≥ ≤
[symbols to copy]
1) What information can peak flow readings provide?
2) How do peak flow readings help us treat asthma?
1) Quantifies what the patient can do
2)
- Helps predict exacerbations by comparing readings to population norms or personal best
- Drives the asthma action plan
1) What information can peak flow readings provide?
2) How do peak flow readings help us treat asthma?
1) Quantifies what the patient can do
2)
- Helps predict exacerbations by comparing readings to population norms or personal best
- Drives the asthma action plan
How is asthma diagnosed with spirometry?
1) must see reversibility of obstruction with a SABA
> 200 mL ↑
≥ 12% ↑ from baseline
1) What purpose does predicted FEV1 % serve in asthma treatment?
2) What can FEV1/FVC ratio be used for in asthma treatment planning
1) normalizes pt char (height, sex, age, ethnicity)
2) used if restricted lung vol suspected
- chest wall ↓ expansion = kyphosis
- pulm fibrosis
- neuromuscular disorders
What are the Asthma Action Plans (AAP) based on?
- daily checks of peak expiratory flow (aka FEV1)
How are AAPs used?
- used to identify obstruction before Sx occur –> exacerbation
- aim to reverse dmg in early stages
List the FEV1 criteria for each chronic asthma classification
Interm and Mild Persist = > 80%
Mod Persist = 60 - 80%
Sev Persist = < 60%
What are the instructions for proper MDI use?
1) Remove dust cap
2) Shake well, 3-4 times
3) Hold inhaler in front of open mouth
4) Exhale completely
5) Begin inhalation
6) After ~ 1 sec actuate inhaler and breath in slowly
7) Hold breath as long as comfortable (avoid coughing)
1) How long should you wait btw puffs?
2) Why should you wait this long?
1) 1-2 mins
2) Allows bronchodilators to open airways for second dose or next Rx
Advantages of spacers
- ↓ oropharyngeal deposition
- enhanced lung delivery
- ↓ need for good hand-lung coordination
How do spacers ↑ efficacy and ↓ SE with MDI use?
- big droplets hit side of spacer –> ↓ SE
- small droplets left and are more easily inhaled
What are two differences btw MDIs and dry powder inhalers (DPI)?
- MDIs require slow, controlled inspiration while DPIs require ↑ inspiratory flow (more forceful)
- You want to avoid cough reflex in MDI while in DPIs coughing may occur regardless d/t pwdr
1) How do nebulizers work?
2) Advantages?
3) Disadvantages?
1) pressure or vibration to aerosolize
2) Adv
- no special techniques
- Pts like added O2
- useful if Pt unable to take deep/full breath
3) Disadv
- require electricity (plug or battery)
- longer duration of Tx
1) What are the acute rescue asthma meds
2) What is the one LABA used for acute exacerbation
3) What are the prevention asthma meds
1) SABA, anti-ACh/SAMA, systemic corticosteroids
2) Formoterol/Budesonide (symbicort)
3) ICS, LABA, mast-cell stabilizers (MCS), leukotriene modifiers, methylxanthines, MABs
1) What are the indications for SABAs
2) MoA
3) ADR
4) How can you tell if a Pt needs their rescue meds adjusted?
1)
- quick relief of acute asthma Sx (why used 1st)
- preventative before trigger exposure (EIB or EIA)
2) stim B2 receptors –> smooth muscle relaxation –> bronchodilation
3) Tremor, tachycardia, palpitations, nervous, restlessness
4) By monitoring their refill history, > 1 canister/mo –> inadequate prevention control
1) What ate the 2 SAMAs for asthma
2)Why should SAMAs not be used as monotherapy?
23 Why is open-mouth technique not used with SAMAs?
1) Ipatropium, Oxitropium
2) Slower onset and less effective vs SABA
3) Rx may get into eyes –> ↓ ocular moisture and cornea dryness/abrasions
What are the indications for SAMA?
- relief of acute bronchospams, but never used alone
- not for routine outpatient use
- provides additive (15-20%) to SABA
- no effect on EIA
1) What is Primatene Mist?
2) Indications
1) Racemic epinephrine (equal ratios of enantomers)
2) FDA approved for mild-intermittent asthma
Drawbacks of Primatene Mist?
- less effective that SABAs
- ↑ potential for ADRs (@ ↑ doses that rescue dose)
- Self Tx not recommended –> encourage Pts to seek counsel
Available forms of Systemic Corticosteroids (SCS)?
- methylprednisalone (Solo-Medrol) - IV
- prednisolone (Predone) - syrup
- prednisone/dexmethasone - oral tabs
Why are SCS used in asthma Tx?
- prevent progression if exacerb occurs
- reverse inflamm (↓ hyperreact, ↓ long-term dmg)
- speed recovery and ↓ relapse rate
How long should SCSs be used?
short-term only (3-10 days)
What makes dexmethasone diff vs other short course SCS in terms of dosing?
- must use shorter course (1-2 days)
- longer DoA b/c T 1/2 = 36-72 hrs
- –> take for 2 days = lasts 5-7 days
What are the short course SCS ADRs?
- ↑ blood CHO
- fluid ret and ↑ appetite –> wt gain
- mood swings
- ↑ BP
- weight gain
- GI ulcers not common in short course SCS
What are the long-term use ADRs for SCS?
- adrenal axis suppression
- impaired immune fxn
- Cushing’s/Cushinoid Sx
- etc…
How are Inhaled Corticosteroids (ICS) used in asthma Tx?
- As 1st line controllers for asthma prevention for all ages
- To ↓ hyperresp to triggers (anti-inflamm)
How could you respond to parent’s concerns regarding growth suppression while on ICS?
- Only potential, not definite
- In RCT, 1.2 cm (1/2 “) diff btw some kids only after following for 4-6 yrs
- May ‘catch-up’ after Tx
- Suppression not meaningful enough vs effects of long-term illness
- the 1/2 inch is height not length or girth
ICS ADRs?
- cough
- oral thrush
- hoarseness
- possible systemic SE @ ↑ doses
How to ↓ ADRs w/ ICS?
- use ↓ dose possible to cntrl sx/exacerb
- use aerochamber spacer
- rinse out mouth after inhalation
What are the 3 LABAs for asthma prevention?
- formoterol (Aerolizer) - stand alone
- salmeterol (Serevent) - stand alone
- vilanterol ( only in combo products)
According to Dr. K, why is just saying “ICS” not correct when answering dosing questions?
- b/c you should be able to say “low”, “med”, and “high daily” ICS doses
Describe the diff btw indications for LABAs in asthma vs COPD
- In asthma, LABAs can only be used in addition to ICS
- In COPD, bronchocxn not root cause for exacerb so no need for SABA as rescue –> LABAs ok as monothpy
1) What is the only LABA + ICS combo approved for “rescue” use?
2) Why?
1) formoterol + ICS (Symbicort)
2) Rapid-onset LABA
1) What is the black box warning for LABAs for Pts w/ asthma?
2) Why?
1) LABA not used as monothpy for asthma b/c of ↑↑ in asthma-related deaths
2) LABAs sit on/stim Beta receptors for long periods of time —> ↓ sensitivity and ↓ regulation of Beta receptors
- –> SABA rescue inhalers won’t work when needed
1) What are the 4 LABA + ICS combo brands?
2) Which formulations are interchangable?
3) can HFA and DPI be interchanged for the same formulation
1) Advair, Symbicort, Dulera, Breo
2) None are interchangable
3) NO
What are the two leukotriene receptor antagonists (LRA) for asthma?
- montelukast (Singulair)
- zafirlukast (Accolate)
What role do leukotrienes play in asthma?
- prod by mast cells nd eosinophils
- 1,000 to 10,000x more potent (vs histamines) in causing bronchial smooth muscle cxn
- onset of cxn starts later and lasts longer
LRA MoA?
- blocks leukotriene receptors —> prevent bronchocxn
LRA advantages?
- oral admin
- well tolerated in kids/adults
- useful w/ crappy technique and ↓ inhaler compliance
How are LRAs typically used?
- not for rescue or as a bronchodil
- adjunct mainly in adults
- alt to ICS for kids if growth supp an issue
What are the two methylxanthines available for asthma?
- Theophylline (PO)
- Aminophylline (IV)
1) MoA of methylxanthines (adenosine blocking agents)
2) Why do they suck?
1) smooth muscle relaxant
2)
- no anti-inflamm action
- ADRs not outweigh efficacy
- serum monitoring d/t narrow range (10-20 mcg/ml)
- seizure and dysrrhymia s are serious ADRs
Theophylline and Aminophylline are cousins to what extremely common Rx?
- Caffiene; have same common ADRs as well
When is the monoclonal antibody (MAb) omalizumab (Xolair) indicated for use?
- ≥ 6 yo
- (+) skin test to perennial aeroallergen (all the time and in the air)
- mod/sev pers. asthma not cntrl w/ max dose of 2 best LABA + ICS
When are the MAb mepo-/res- lizumab indicated for use?
- ≥ 18 yo
- Eosinophillic phenotype (specific asthma type)
- Sev pers asthma not cntrl w/ LABA + ICS
MAb ADRs?
- Inj site rxn
- anaphylaxsis
- ↑ CV risk
- Herpes Zoster outbreak
- myalgias/myopathy
What recommendations do you make for all chronic prev asthma Tx plans?
- Pt edu
- Cntrl envir factors
- Mgmt of comorbidities
What is the Quick Relief method for chronic asthma prev planning?
Rx: SABA
Tx: intensity of Rx used based on severity upto 3x of Tx @ 20 min intervals; short course oral SCS may be used
What are the Persistent Asthma: Daily Rx general recommendations
- Step 2-4 consider subcut allergen immuno shots
- ≥ Step 4 —> asthma specialist
- Step 3 —> consider consult
What is step 1 for chronic asthma prev planning?
- Intermittent (SABA PRN)
- Basically the Quick Relief step
What are the Persistent Asthma: Daily Medication recommendations for Step 2-6
Step 2: SABA + low dose ICS
Step 3: SABA + low dose ICS + LABA
or SABA + med dose ICS
Step 4: SABA + med dose ICS + LABA
Step 5: SABA + high dose ICS + LABA > consider omalizumab
Step 6: SABA + high dose ICS + LABA + oral SCS and consider omalizumab
What should be done before each step up the Persistent Asthma: Daily Rx plan?
- check adherence
- envir cntrl
- comorbid conditions
How can Pts step down the Persistent Asthma plan?
if asthma is well cntrl @ least 3 mo
Vaccinations for COPD
influenza
pneumococcal
How do you continually reeval during Persistent Asthma planning?
- Continually reassess for step ↑ or ↓
- Monitor SABA use (> 1 canister = asthma not well cntrl)
- Watch inhaler use (correct technique, encourage spacer use)
How do you continually reeval during Persistent Asthma planning?
- Continually reassess for step ↑ or ↓
- Monitor SABA use (> 1 canister = asthma not well cntrl)
- Watch inhaler use (correct technique, encourage spacer use)
intermittent vs continuous O2 COPD
intermittent only during exacerbation
continuous only affects survival if >15h/D
1) How long before activity should a LABA be used?
2) Other considerations if LABAs used for EIA/EIB?
1) Use LABAs 15-30 mins before activity
2)
- use LABAs with longer activities
- not for frequent use
- Black Box warning for chronic LABA use w/o ICS
1) What is “Mild” severity for Home Mgmt of Exacerb
2) Clinical course
1)
- SOB w/ activity
- > 70% of FEV1 / PEF (predict / personal best)
2)
- care @ home
- prompt relief w/ SABA
- possible short course
1) What is “Moderate” severity for Home Mgmt of Exacerb
2) Clinical course
1)
- SOB limit usual activity
- 40 to 69% FEV1 / PEF
2)
- Office visit or ED
- relief w/ frequent SABA and oral SCS
- Sx last 1-2 days
COPD
D)
if CAT <20 LAMA if fails progress to LABA+LAMA and up
if CAT >=20 LABA+LAMA if fails LABA+LAMA+ICS
if eso LABA + ICS if fails LABA+LAMA+ICS
1) What is “Mild” severity of exacerb
2) What do you do?
1)
- SOB w/ activity
- > 70% of FEV1 / PEF (predict / personal best)
2)
- care @ home
- prompt relief w/ SABA
- possible short course
COPD
D)
if CAT <20 LAMA if fails progress to LABA+LAMA and up
if CAT ≥ 20 LABA+LAMA if fails LABA+LAMA+ICS
if eso LABA + ICS if fails LABA+LAMA+ICS
1) What is “Life Threatening” severity for Home Mgmt of Exacerb
2) Clinical course
1)
- Severe SOB and no able to speak
- < 25% FEV1 / PEF
2)
- Hospitalization (ICU possible)
- minimal or no relief from SABA and IV SCS
1) What is “Moderate” severity of exacerb
2) What do you do?
1)
- SOB limit usual activity
- 40 to 69% FEV1 / PEF
2)
- Office visit or ED
- relief w/ frequent SABA and oral SCS
- Sx last 1-2 days
1) What is “Severe” severity of exacerb
2) What do you do?
1)
- SOB @ rest
- < 40% FEV1/PEF
2)
- ED —> hospitalization likely
- partial relief w/ freq SABA and oral SCS
- Sx last for > 3 days
1) What is “Life Threatening” severity of exacerb
2) What do you do?
1)
- Severe SOB and no able to speak
- < 25% FEV1 / PEF
2)
- Hospitalization (ICU possible)
- minimal or no relief from SABA and IV SCS
Step 1 of Exacerb Home Mgmt: Assess Severity
- Seek immediate med thpy if:
- PEF < 50%
- marked breathlessness
- unable to speak except short phrases
- use of accessory muscles
- drowsiness r/t ↓ O2
COPD
GOLD 1
2
3
41) ≥ 80% FEV/FC MILD “RISK OF”
2) 50-80% MODERATE
3) 30-50% SEVERE
4)<30% VERY SEVERE “THEIR SCREWED”
DIAGNOSIS >70%
What is a good response from SABA home use for exacerb?
- no wheeze or SOB
- PEF ≥ 80%
What is the action plan following a good response from SABA use s/p home exacerb?
- contact clinic to f/u
- cont SABA 2-4 puffs Q 3-4 hrs for 48hrs
- may start short course SCS
What is an incomplete response from SABA home use for exacerb?
- persist wheeze
- PEF 50-80%
What is the action plan following an incomplete response from SABA use s/p home exacerb?
- SABA 2-4 puffs Q hourly + oral SCS
- contact clinic same day for further instructions
What is a poor response from SABA home use for exacerb?
- marked wheeze and SOB
- PEF < 50%
What is the action plan following a poor response from SABA use s/p home exacerb?
- SABA 4-6 puffs immed + oral SCS
- contact clinic OTW to ED
Which Pts need Spirometry?
- dyspnea
- chronic cough
- chronic sputum
- Hx risk factors
C D
A B
HOSP 2+ C D
1> A B
CAT<10 CAT>10 symptoms
COPD
A)
B)
C)
A) Any broncho => change it up
B) LAMA or LABA => both
C) LAMA =>both or LABA ICS if eso.
