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Karboski's Pharmacology - UT AEMSN > Respiratory - Asthma & COPD > Flashcards

Respiratory - Asthma & COPD Flashcards

1
Q

Describe how asthma –> airway remodeling

A

Asthma trigger
–> inflammation and acute broncho cxn
–> neutrophil and eosinophil infiltration
–> basement membrane thickening and goblet cell
proliferation

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2
Q

Why is wheezing not a good measure of asthma exacerbation?

A

B/C absence of wheezing can either me resolution of the issue or complete closure of the airways

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3
Q

What are the two main goals of asthma management?

A

1) Open airway and ease breathing

2) Prevent or limit inflammation

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4
Q

What is the primary difference asthma and COPD?

A
  • the reversibility of the changes occurring with each exacerbation
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5
Q

1) What does spirometry measure?

2) What pulmonary function definition does spirometry correlate to?

A

1) volume and force of air expired

2) forced vital capacity (FVC)

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6
Q

1) Why is spirometry a diagnostic measure of asthma?

2) What is the purpose of doing a pre and post bronchodilator?

A

1) Because it measures degree of severity

2) Evaluate the degree of reversibility

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7
Q

How would you instruct a patient to use a spirometer?

A
  • Take a full breath in
  • Then blow out your full breath as fast as you can

May need 2-3 practice trials

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8
Q

↑↓ ≥ ≤

A

[symbols to copy]

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9
Q

1) What information can peak flow readings provide?

2) How do peak flow readings help us treat asthma?

A

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

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10
Q

1) What information can peak flow readings provide?

2) How do peak flow readings help us treat asthma?

A

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

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11
Q

How is asthma diagnosed with spirometry?

A

1) must see reversibility of obstruction with a SABA
> 200 mL ↑
≥ 12% ↑ from baseline

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12
Q

1) What purpose does predicted FEV1 % serve in asthma treatment?
2) What can FEV1/FVC ratio be used for in asthma treatment planning

A

1) normalizes pt char (height, sex, age, ethnicity)
2) used if restricted lung vol suspected
- chest wall ↓ expansion = kyphosis
- pulm fibrosis
- neuromuscular disorders

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13
Q

What are the Asthma Action Plans (AAP) based on?

A
  • daily checks of peak expiratory flow (aka FEV1)
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14
Q

How are AAPs used?

A
  • used to identify obstruction before Sx occur –> exacerbation
  • aim to reverse dmg in early stages
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15
Q

List the FEV1 criteria for each chronic asthma classification

A

Interm and Mild Persist = > 80%
Mod Persist = 60 - 80%
Sev Persist = < 60%

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16
Q

What are the instructions for proper MDI use?

A

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)

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17
Q

1) How long should you wait btw puffs?

2) Why should you wait this long?

A

1) 1-2 mins

2) Allows bronchodilators to open airways for second dose or next Rx

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18
Q

Advantages of spacers

A
  • ↓ oropharyngeal deposition
  • enhanced lung delivery
  • ↓ need for good hand-lung coordination
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19
Q

How do spacers ↑ efficacy and ↓ SE with MDI use?

A
  • big droplets hit side of spacer –> ↓ SE

- small droplets left and are more easily inhaled

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20
Q

What are two differences btw MDIs and dry powder inhalers (DPI)?

A
  • 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
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21
Q

1) How do nebulizers work?
2) Advantages?
3) Disadvantages?

A

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

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22
Q

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

A

1) SABA, anti-ACh/SAMA, systemic corticosteroids
2) Formoterol/Budesonide (symbicort)
3) ICS, LABA, mast-cell stabilizers (MCS), leukotriene modifiers, methylxanthines, MABs

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23
Q

1) What are the indications for SABAs
2) MoA
3) ADR
4) How can you tell if a Pt needs their rescue meds adjusted?

A

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

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24
Q

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?

A

1) Ipatropium, Oxitropium
2) Slower onset and less effective vs SABA
3) Rx may get into eyes –> ↓ ocular moisture and cornea dryness/abrasions

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25
Q

What are the indications for SAMA?

A
  • relief of acute bronchospams, but never used alone
  • not for routine outpatient use
  • provides additive (15-20%) to SABA
  • no effect on EIA
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26
Q

1) What is Primatene Mist?

2) Indications

A

1) Racemic epinephrine (equal ratios of enantomers)

2) FDA approved for mild-intermittent asthma

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27
Q

Drawbacks of Primatene Mist?

A
  • less effective that SABAs
  • ↑ potential for ADRs (@ ↑ doses that rescue dose)
  • Self Tx not recommended –> encourage Pts to seek counsel
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28
Q

Available forms of Systemic Corticosteroids (SCS)?

A
  • methylprednisalone (Solo-Medrol) - IV
  • prednisolone (Predone) - syrup
  • prednisone/dexmethasone - oral tabs
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29
Q

Why are SCS used in asthma Tx?

A
  • prevent progression if exacerb occurs
  • reverse inflamm (↓ hyperreact, ↓ long-term dmg)
  • speed recovery and ↓ relapse rate
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30
Q

How long should SCSs be used?

A

short-term only (3-10 days)

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31
Q

What makes dexmethasone diff vs other short course SCS in terms of dosing?

A
  • 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
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32
Q

What are the short course SCS ADRs?

A
  • ↑ blood CHO
  • fluid ret and ↑ appetite –> wt gain
  • mood swings
  • ↑ BP
  • weight gain
  • GI ulcers not common in short course SCS
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33
Q

What are the long-term use ADRs for SCS?

A
  • adrenal axis suppression
  • impaired immune fxn
  • Cushing’s/Cushinoid Sx
  • etc…
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34
Q

How are Inhaled Corticosteroids (ICS) used in asthma Tx?

A
  • As 1st line controllers for asthma prevention for all ages

- To ↓ hyperresp to triggers (anti-inflamm)

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35
Q

How could you respond to parent’s concerns regarding growth suppression while on ICS?

A
  • 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
36
Q

ICS ADRs?

A
  • cough
  • oral thrush
  • hoarseness
  • possible systemic SE @ ↑ doses
37
Q

How to ↓ ADRs w/ ICS?

A
  • use ↓ dose possible to cntrl sx/exacerb
  • use aerochamber spacer
  • rinse out mouth after inhalation
38
Q

What are the 3 LABAs for asthma prevention?

A
  • formoterol (Aerolizer) - stand alone
  • salmeterol (Serevent) - stand alone
  • vilanterol ( only in combo products)
39
Q

According to Dr. K, why is just saying “ICS” not correct when answering dosing questions?

A
  • b/c you should be able to say “low”, “med”, and “high daily” ICS doses
40
Q

Describe the diff btw indications for LABAs in asthma vs COPD

A
  • 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

41
Q

1) What is the only LABA + ICS combo approved for “rescue” use?
2) Why?

A

1) formoterol + ICS (Symbicort)

2) Rapid-onset LABA

42
Q

1) What is the black box warning for LABAs for Pts w/ asthma?
2) Why?

A

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

43
Q

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

A

1) Advair, Symbicort, Dulera, Breo
2) None are interchangable
3) NO

44
Q

What are the two leukotriene receptor antagonists (LRA) for asthma?

A
  • montelukast (Singulair)

- zafirlukast (Accolate)

45
Q

What role do leukotrienes play in asthma?

A
  • 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
46
Q

LRA MoA?

A
  • blocks leukotriene receptors —> prevent bronchocxn
47
Q

LRA advantages?

A
  • oral admin
  • well tolerated in kids/adults
  • useful w/ crappy technique and ↓ inhaler compliance
48
Q

How are LRAs typically used?

A
  • not for rescue or as a bronchodil
  • adjunct mainly in adults
  • alt to ICS for kids if growth supp an issue
49
Q

What are the two methylxanthines available for asthma?

A
  • Theophylline (PO)

- Aminophylline (IV)

50
Q

1) MoA of methylxanthines (adenosine blocking agents)

2) Why do they suck?

A

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

51
Q

Theophylline and Aminophylline are cousins to what extremely common Rx?

A
  • Caffiene; have same common ADRs as well
52
Q

When is the monoclonal antibody (MAb) omalizumab (Xolair) indicated for use?

A
  • ≥ 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
53
Q

When are the MAb mepo-/res- lizumab indicated for use?

A
  • ≥ 18 yo
  • Eosinophillic phenotype (specific asthma type)
  • Sev pers asthma not cntrl w/ LABA + ICS
54
Q

MAb ADRs?

A
  • Inj site rxn
  • anaphylaxsis
  • ↑ CV risk
  • Herpes Zoster outbreak
  • myalgias/myopathy
55
Q

What recommendations do you make for all chronic prev asthma Tx plans?

A
  • Pt edu
  • Cntrl envir factors
  • Mgmt of comorbidities
56
Q

What is the Quick Relief method for chronic asthma prev planning?

A

Rx: SABA
Tx: intensity of Rx used based on severity upto 3x of Tx @ 20 min intervals; short course oral SCS may be used

57
Q

What are the Persistent Asthma: Daily Rx general recommendations

A
  • Step 2-4 consider subcut allergen immuno shots
  • ≥ Step 4 —> asthma specialist
  • Step 3 —> consider consult
58
Q

What is step 1 for chronic asthma prev planning?

A
  • Intermittent (SABA PRN)

- Basically the Quick Relief step

59
Q

What are the Persistent Asthma: Daily Medication recommendations for Step 2-6

A

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

60
Q

What should be done before each step up the Persistent Asthma: Daily Rx plan?

A
  • check adherence
  • envir cntrl
  • comorbid conditions
61
Q

How can Pts step down the Persistent Asthma plan?

A

if asthma is well cntrl @ least 3 mo

62
Q

Vaccinations for COPD

A

influenza

pneumococcal

63
Q

How do you continually reeval during Persistent Asthma planning?

A
  • Continually reassess for step ↑ or ↓
  • Monitor SABA use (> 1 canister = asthma not well cntrl)
  • Watch inhaler use (correct technique, encourage spacer use)
63
Q

How do you continually reeval during Persistent Asthma planning?

A
  • Continually reassess for step ↑ or ↓
  • Monitor SABA use (> 1 canister = asthma not well cntrl)
  • Watch inhaler use (correct technique, encourage spacer use)
64
Q

intermittent vs continuous O2 COPD

A

intermittent only during exacerbation

continuous only affects survival if >15h/D

65
Q

1) How long before activity should a LABA be used?

2) Other considerations if LABAs used for EIA/EIB?

A

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

66
Q

1) What is “Mild” severity for Home Mgmt of Exacerb

2) Clinical course

A

1)
- SOB w/ activity
- > 70% of FEV1 / PEF (predict / personal best)
2)
- care @ home
- prompt relief w/ SABA
- possible short course

67
Q

1) What is “Moderate” severity for Home Mgmt of Exacerb

2) Clinical course

A

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

68
Q

COPD

D)

A

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

69
Q

1) What is “Mild” severity of exacerb

2) What do you do?

A

1)
- SOB w/ activity
- > 70% of FEV1 / PEF (predict / personal best)
2)
- care @ home
- prompt relief w/ SABA
- possible short course

70
Q

COPD

D)

A

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

71
Q

1) What is “Life Threatening” severity for Home Mgmt of Exacerb
2) Clinical course

A

1)
- Severe SOB and no able to speak
- < 25% FEV1 / PEF
2)
- Hospitalization (ICU possible)
- minimal or no relief from SABA and IV SCS

72
Q

1) What is “Moderate” severity of exacerb

2) What do you do?

A

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

74
Q

1) What is “Severe” severity of exacerb

2) What do you do?

A

1)
- SOB @ rest
- < 40% FEV1/PEF
2)
- ED —> hospitalization likely
- partial relief w/ freq SABA and oral SCS
- Sx last for > 3 days

75
Q

1) What is “Life Threatening” severity of exacerb

2) What do you do?

A

1)
- Severe SOB and no able to speak
- < 25% FEV1 / PEF
2)
- Hospitalization (ICU possible)
- minimal or no relief from SABA and IV SCS

75
Q

Step 1 of Exacerb Home Mgmt: Assess Severity

- Seek immediate med thpy if:

A
  • PEF < 50%
  • marked breathlessness
  • unable to speak except short phrases
  • use of accessory muscles
  • drowsiness r/t ↓ O2
76
Q 
COPD
GOLD 1
           2
           3
           4
A

1) ≥ 80% FEV/FC MILD “RISK OF”
2) 50-80% MODERATE
3) 30-50% SEVERE
4)<30% VERY SEVERE “THEIR SCREWED”
DIAGNOSIS >70%

78
Q

What is a good response from SABA home use for exacerb?

A
  • no wheeze or SOB

- PEF ≥ 80%

79
Q

What is the action plan following a good response from SABA use s/p home exacerb?

A
  • contact clinic to f/u
  • cont SABA 2-4 puffs Q 3-4 hrs for 48hrs
  • may start short course SCS
80
Q

What is an incomplete response from SABA home use for exacerb?

A
  • persist wheeze

- PEF 50-80%

81
Q

What is the action plan following an incomplete response from SABA use s/p home exacerb?

A
  • SABA 2-4 puffs Q hourly + oral SCS

- contact clinic same day for further instructions

82
Q

What is a poor response from SABA home use for exacerb?

A
  • marked wheeze and SOB

- PEF < 50%

83
Q

What is the action plan following a poor response from SABA use s/p home exacerb?

A
  • SABA 4-6 puffs immed + oral SCS

- contact clinic OTW to ED

84
Q

Which Pts need Spirometry?

A
  • dyspnea
  • chronic cough
  • chronic sputum
  • Hx risk factors
85
Q

C D

A B

A

HOSP 2+ C D
1> A B
CAT<10 CAT>10 symptoms

86
Q

COPD
A)
B)
C)

A

A) Any broncho => change it up
B) LAMA or LABA => both
C) LAMA =>both or LABA ICS if eso.

Karboski's Pharmacology - UT AEMSN (11 decks)

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