Respiratory Pharmacology Flashcards
Asthma characteristics
- Increase mucous production
- Hyper responsive airways causing broncho-constriction
- Marked airway inflammation
What are the key player in Asthma?
- Mast cells
- IgE
- Immune cells
Early phase of Asthma
Allergen that leads to mast cell deregulation releasing histamine, luekotrienes, interlukeins, and PGE which creates bronco spasms.
Progression of Early phase Asthma to Late phase Asthma
infiltration of inflammatory cells: release cytokines, interleukin, and other inflammatory mediators
Late phase Asthma
- Airway inflammation leading to airflow limitation leading to bronchospasm and increase airway responsiveness
- Edema
- endothelial injury
- Impaired mucocillary function
Symptom Triggers of Asthma
- Upper Respiratory viral infections
- allergens
- exercise
- stress
- Exposure to inhaled irritants
- GERD
- Aspirin
- Exposure to sulfates (wine)
How does Aspirin cause an Asthma attack?
Aspirin causes a pseudo reaction to NSAIDS by inhibiting COX 1 and initiating COX 2 and can take up to 20 minutes to 3 hours
If a patient needs to be on aspirin what can we prescribe the patient to prevent an asthma attack
Monoleucast (singular)
Diagnostic Criteria for Asthma
- The presence of symptoms consistent with asthma: wheezing, SOB, cough, chest tightness
- The presence of variable airflow limitation
- measured by spirometry
- Reversibility of airflow
Factors increasing risk for asthma exacerbation
- Uncontrolled Asthma symptoms
- Use of more than 200 meter dose short acting bronchodilator canisters a month
- Inadequate inhaled corticosteroids
- Cost
Classification of Asthma: Intermittent
Less than 2 days per week, air flow normal
Classification of Asthma: Mild Persistent
More than 2 days a week but not daily spirometry is normal
Classification of Asthma: Moderate Persistent
Daily symptoms and 60-80 % normal airflow
Classification of Asthma: severe persistent
continual symptoms; results of peak flow spirometry is less than 60 % normal
GINA asthma criteria steps
- Assess
- Adjust
- Review
GINA step 1: Preferred controller
- As need low dose ICS- Formoterol
GINA step 2: Preferred Controller
- Daily low dose inhaled corticosteroid
2. or as needed ICS- Formoterol
GINA step 3: Preferred Controller
- Lose dose ICS and LABA
GINA step 4: Preferred Controller
- Medium dose ICS and LABA
GINA step 5: Preferred Controller
- High dose ICS and LABA
2. Refer to phenotypic assessment
GINA Preferred Step Reliever for Stage 1 and 2
As needed low dose ICS formoterol
Stage 1
Symptoms less than twice a month
Stage 2
Symptoms twice a month or more but not daily
Stage 3
Symptoms most days or walking with asthma once a week or more
Stage 4
Symptoms most days or walking with asthma once a week or more, and low lung function
Preferred Reliever Stages 3-5
As needed low dose ICS-formoterol for patients prescribed maintenance and reliever therapy
Asthma Assessment
- Confirmation of diagnosis
- Symptoms control and modifiable risk factors
- Cormobidities
- Inhaler technique and adherence
- Patients preference and goals
How to use a pressurized meter dose inhaler
- push to prime
- press down and inhale (in the patients mouth or close to it)
- Hold breathe for 10 seconds
- slowly exhale
- Rinse mouth afterwards due to increase risk of fungal infections
This drug class interferes with gene transcription and activation of inflammatory mediators and stabilizes cellular membrane
Inhaled corticosteroids
Example of an inhaled corticosteroids
Budesinode (Pulmoncort)
Adverse effects of Budesinode
- Pharyngeal irritations
- Dry mouth
- Oral fungal infections
This class of drugs stimulate beta 2 adrenergic receptors relax airway smooth muscle and increase bronchial cillary activity
Beta 2 adrenergic agonists
Short acting beta agonists
- Albuterol (Proventil)
2. Levabuterol (Xopenex)
SABA’s are used for..
Acute relief of bronchospasm within four hours
Adverse effects of beta 2 adrenergic agonists
- hypokalemia
- hyperglycemia
- CNS stimulation
- increased skeletal muscle activity
Long acting beta 2 agonists
- formoterol + budsenomide (symbicort)
This drug class competitively binds or inhibits proinflammatory leukotriene
Leukotriene modifiers
Example of a leukotriene modifier
Montelukast (singuliar)
Black box warning for montelukast
neuropsychiatric events- includes suicide in adults and teens
nightmares in children
What are the biologic agents that treat asthma based on IL phenotype?
- Mepolizumab (Nucala)
- Reslizumab (Cingar)
- Benlarizumab ( fasenra)
- Dupliumab (Dupixent)
Before starting a biologic treatment on a patient the provider must check..
a serum IgE level
What monoclonal antibody is used for asthma prophylaxis
Omalizumab (Xolair)
How does omalizumab (Xolair) work?
Attaches to the receptor on IgE and prevents the IgE mediated release of inflammatory mediators
omalizumab (Xolair) BLACK BOX warning
Anaphylaxis; monitor patient for several hours after administration
Who can take omalizumab (Xolair)
reserved only for patients with persistent asthma not controlled by corticosteroids or other agents
Signs and Symptoms of COPD
- ongoing cough
- SOB
- Wheezing
- Chest tightness
This disease cause abnormal enlargement of air spaces distal to the terminal broncholies and leads to destruction of aveolar walls with air trapping and expiratory flow impairment
COPD
Main cause of COPD
smoking
Diagnostic Criteria for COPD
- Chronic cough with or without sputum production
- Persistent progressive dyspnea that worsens with exercise
- May or may not have chest tightness
- May or may not having wheezing, cyanosis, barrel shaped chest, low diaphragms and for pulmonale
What is required for the diagnosis of COPD
Spirometry and less than 70% is the diagnosis
Diagnostic Criteria for COPD spirometry
Preformed without a bronchodilator and then with a bronchodilator to evaluate the difference between in air flow limitation
Community acquired pneumonia treatment for outpatient without comorbiditie’s
- Doxycycline
- Amoxicillin
- Marcolides
Community acquired pneumonia treatment for outpatient with comorbiditie’s
- Bactrim + doxycycline
2. fluorquinolines
Community acquired pneumonia is usually caused by what organism
Strep. pneumonia
Inpatient treatment for MRSA
- Vancomycin
2. Linezolid
Inpatient treatment for PSA
- cefepime
- Ceftazidine
- Aztreonam
- Meropenem
- Imipinem
Most common cause of bronchitis
viral infections
Mom common cause of bacterial bronchitis
Bordetella pertusis
Acute bronchitis
less than 3 weeks
Supportive care for patients with bronchitis
- Hydration
- Tea
- Honey
- cough suppressant
- Throat lozenges
Indications for antibiotic use in patients with bronchitis
- Prolonged symptoms > 3 weeks
- postive cultures
- High Fevers
- Purulent sputum
- Respiratory symptoms for longer than 4-6 days
- People over 65 years old
- Patients with chronic diseases
How do you treat B. Pertussis
Marcolide
How do you treat M.pneumoniae
Macrolide or doxycycline
Community acquired pneumonia
Acute infection of the lower respiratory tract that is usually associated with symptoms of acute infection and acute infiltrates detected by chest x-ray or chest ultrasound
COVID 19 and asthma using spirometry
- Avoid spirometry in patients with confirmed or suspected covid because it can disseminate viral particles and expose the infection to staff and other patients
