Respiratory System (part 2) Flashcards
What is asthma?
A reversible airway obstruction & bronchia hyperresponsiveness w an underlying inflammatory component
List etiology of asthma Hint: 4
1) Environmental
2) Genetic
3) Allergies
4) Others: Exercise, Certain drugs, GERD, Stress, ↑ emotions
List 6 environmental etiologies of asthma
1) Pollen
2) Molds
3) Dust mites
4) Animal dander
5) Smoking
6) Weather changes
What type of response does asthma have?
An immunoglobulin E (IgE) mediated response (Atopic sensitization)
What age group is asthma most commonly seen in?
Can occur at any age; most common in children & older adults
List the 3 major components of asthma
1) bronchoconstriction
2) airway inflammation
3) bronchial hyperresponsiveness
How does bronchoconstriction occur?
In response to a trigger
How does airway inflammation occur?
Due to T-helper cells and IgE mediated pathways
How does bronchial hyperresponsiveness occur?
Due to activated mast cells which lead to release of inflammatory mediators (histamine, prostaglandins, & leukotrienes)
What could happen overtime in relation to asthma?
Airway thickening & hyperplasia of the smooth muscle may lead to remodeling of lung tissue
List 5 things leukotrienes cause
1) Inflammation
2) Bronchoconstriction
3) Mucus production
4) Infiltration of inflammatory cells into airway wall
5) ↑ vascular permeability
What two things cause airway hyperresponsiveness?
Inflammation & asthma
What does inflammation and asthma limit?
Airflow
What type of Sx do we see associated with inflammation & asthma?
Respiratory Sx
What causes airway narrowing of the smooth muscle?
Bronchoconstriction
Inflammation & asthma causes airway ____
edema
Inflammation & asthma causes inflamed…
Mucus hypersecretion with plugging
Inflammation & asthma:
What does hypertrophy of airways and smooth muscles lead to?
Remodeling where changes are only partially reversible
List 6 clinical manifestations of asthma
1) Dyspnea
2) Wheezing
3) Cough
4) Prolonged expiration
5) Chest tightness
6) Use of accessory muscles
Severity of asthma is dependent on….
The degree of bronchial constriction
How does exercise-induced asthma occur? Hint: 2
1) Occurs when airways narrow during physical activity
2) Caused by: air, air pollution, chlorine in pools, etc
List 3 Sx of exercise-induced asthma
1) SOB
2) Wheezing
3) Coughing
& other Sx
Who can we see exercise-induced asthma in?
Those without asthma & elite athletes
What is the Tx for exercise-induced asthma?
Short-acting beta-agonists (SABAs) → take before exercising
List 2 short-acting beta-agonists (SABAs)
1) Albuterol (ProAir HFA; Proventil-HFA; Ventolin HFA)
2) Levalbuterol (Xopenex HFA)
How do SABAs work?
Inhaled medicines that help open airways
Should NOT be used every day as it can make them less effective
List another Tx option used for exercise-induced asthma that relaxes the airways
Ipratropium (Atrovent HFA)
What is nocturnal asthma?
When asthma Sx are often worse at night & may disrupt sleep
List 6 causes of nocturnal asthma
1) Reclining position
2) ↑ mucus production/ drainage
3) Hormone level changes
4) Allergens
5) Stress
6) Obesity
List 3 Sx of nocturnal asthma
1) Wheezing
2) Chest tightness
3) Difficulty breathing at night
List 4 Tx options for nocturnal asthma
1) Montelukast (singulair)
2) Albuterol
3) Long-acting Beta-Agonists
4) Leukotrienes
What is status asthmaticus?
Acute, severe asthma that is refractory to Tx
Can be life-threatening
List the sequence of events that occurs in status asthmaticus Hint: 5
Pathologic changes in airway → airflow obstruction → premature closure on expiration → dynamic hyperinflation → hypercarbia
What 2 things may or may not be seen in patient w status asthmaticus?
1) Wheezing
2) Cough
List 6 non-pharmacological management options for asthma
1) Identify triggers/ risk factors
2) Breathing exercises
3) Diet
4) Acupuncture, yoga
5) Avoid smoking
6) Patient education
List 8 pharmacological management options for asthma
1) Adrenergic (SABAs/ LABAs)
2) Anti-cholinergic
3) Methylxanthines
4) Inhaled corticosteroids
5) Leukotriene modifiers
6) Mast cell stabilizer
7) Immunosuppressant monoclonal Ab
8) Adjuvant medications
List 4 types of bronchodilators
1) Beta 2 adrenergic agonists
2) Muscarinic antagonists
3) Leukotriene receptor antagonists
4) Methylxanthines
List 2 examples of beta-2 adrenergic agonists
AKA: sympathomimetic
1) Short-acting (SABA)
2) Long-acting (LABA)
How do beta-2 adrenergic agonists work? Hint: 3
1) Cause smooth muscle relaxation in the lungs, muscles, & liver
2) Vasodilation of the bronchial passage
3) Release of insulin
List 7 side effects of beta-2 adrenergic agonists
1) Tachycardia
2) Tremors/ shakiness
3) Palpitations
4) Anxiety
5) Sweating
6) Arrhythmias
7) Insomnia
A pt taking beta-2 adrenergic agonists should avoid use of what two med classes?
1) Beta blockers
2) NSAIDs
Short-acting beta agonists (SABAs) Hint: 2
1) Known as “Rescue drug”
2) Always used first to Tx an acute attack
Explain administration of SABAs Hint: 3
1) Shake inhaler before use
2) 2-4 puffs every 20 min, up to 3 doses
3) No relief, call physician
List 5 medications considered to be SABAs
1) Albuterol (ProAir, Ventolin, Proventil)
2) Levalbuterol (Xopenex)
3) Metaproterenol (Alupent)
4) Terbutaline (Brethine, Brethaire)
5) Pirbuterol (MaxAir)
Which SABA is considered a beta2 agonists with minor beta1 activity?
Albuterol
Explain administration of albuterol for exercise-induced asthma
2-5 puffs 15-30 min before exercising
Explain administration of albuterol for bronchospasm/ constriction
1) Inhaler solution: 3-4 x a day
2) Inhaled powder: 3-4 x a day
What pregnancy category is albuterol?
Category C
List 3 routes of administration for albuterol
1) Oral
2) Multi-dose inhaler
3) Nebulizer
List 8 side effects of albuterol
1) Muscle tremors
2) Cardiac: angina; tachycardia; palpitations
3) CNS: agitation; anxiety; insomnia; seizures
List 5 contraindications of using albuterol
1) Hypersensitivity
2) CAD
3) HTN
4) Diabetes
5) Seizure disorders
List 4 things to note about long-acting beta-agonists (LABAs)
1) Known as “maintenance drug”
2) Often used in combo with a steroid
3) Comes in inhaler- metered-dose or dry powder
4) Allows airway to stay open
List 4 examples of medications considered LABAs
1) Salmeterol (serevent)
2) Formoterol (Foradil)
3) Indacaterol (Arcapta neohaler)
4) Vilanterol
Black box warning of LABAs
Salmeterol & Formoterol should NOT be used w/o a steroid in asthma for ALL ages
Need to weight risk vs. benefit
What is typical half-life of LABAs
12 hours
What should LABAs never be used as?
A rescue inhaler
LABAs should not be used in what age group?
Children < 4 yrs & never w/o a steroid
Why are LABAs used for patients with COPD?
To reduce exacerbation
Muscarinic antagonists are also known as _____
Anticholinergics
How do muscarinic antagonists work?
Blocks muscarinic cholinergic receptors by antagonizing the neurotransmitter acetylcholine in smooth muscle
List 3 routes of admin for muscarinic antagonists
1) Nebulizer
2) Meter-dose inhaler
3) Oral
When are muscarinic antagonists used?
After a SABA
List 2 local side effects of muscarinic antagonists
1) Dry mouth
2) Hoarseness
List 5 systemic side effects of muscarinic antagonists
1) Dizziness
2) H/A
3) Fatigue
4) Palpitations
5) Urinary retention
List an example of a short-acting muscarinic antagonist (SAMA)
Ipratropium bromide (Atrovent)
List 3 things to note about Ipratropium bromide (SAMA)
1) Can cause anticholinergic side effects
2) NOT used for acute bronchospasms
3) Can NOT use if allergic to peanuts or soy products
List an example of a long-acting muscarinic antagonist (LAMA)
Tiotropium Bromide (Spiriva)
List 3 things to note about Tiotropium bromide (LAMA)
1) Inhibits the muscarinic M3 receptors in the lungs
2) Can cause cough/ dry mouth
3) NOT for acute bronchospasm
Pathophysiology of muscarinic receptors
They control smooth muscle tone, mucus secretion, vasodilation & inflammation
Pathophysiology of muscarinic receptors in COPD & asthma
Cholinergic (parasympathetic) mechnaisms contribute to ↑ bronchoconstriction & mucus secretion that limit airflow
Muscarinic receptors:
List sympathetic & parasympathetic responses for eyes
S: Dilates pupils
P: Constricts pupils
Muscarinic receptors:
List sympathetic & parasympathetic responses for lungs
S: Dilates bronchioles
P: Constricts bronchioles & increase secretions
Muscarinic receptors:
List sympathetic & parasympathetic responses for heart
S: Increases HR
P: Decreases HR
Muscarinic receptors:
List sympathetic & parasympathetic responses for blood vessels
S: Constricts
P: Dilates
Muscarinic receptors:
List sympathetic & parasympathetic responses for GI
S: Relaxes smooth muscles of GIT
P: increases peristalsis
Muscarinic receptors:
List sympathetic & parasympathetic responses for bladder
S: Relaxes bladder muscle
P: Constricts bladder
Muscarinic receptors:
List sympathetic responses for uterus
S: Relaxes uterine muscles
Muscarinic receptors:
List parasympathetic responses for salivary gland
P: Increases salivation
What do combination medications contain?
A SAMA and SABA
Never a rescue inhaler
What are methylxanthines?
A group of alkaloids used for their effects as a bronchodilator
When are methylxanthines used?
Currently not supported for asthma guidelines
1) Maybe as 2nd line
2) Used for COPD
List 2 contraindications of Methylxanthines
1) Pregnancy
2) Lactation
Which type of respiratory medication has several drug interactions?
Methylxanthine
List an example of a methylxanthine
Elixophyllin (Theophylline)
Routes of admin for elixophyllin (Theophylline)
1) Oral
2) IV
What does Elixophyllin (Theophylline) require?
drug monitoring due to narrow therapeutic range (10-2 mcg/ mL)
List 5 side effects of Elixophylline (Theophylline)
1) N/V
2) Irritability
3) Tremors
4) Insomnia
5) Tachyarrhythmias
List 2 things to avoid if a patient is on Elixophyllin (Theophylline)
1) Caffeine
2) Smoking
Pathophysiology of corticosteroids Hint: 4
1) Suppress airway inflammation
2) Decrease mucus secretions
3) Suppress release of histamines by mast cells
4) Increase sensitivity of Beta2 adrenergic receptors
What are corticosteroids used to Tx?
Mainstay of asthma Tx and advanced COPD
Approx what % of inhaled steroids make it into the lungs?
10-30%
List 7 medications considered corticosteroids
1) Prednisone (Oral)
2) Beclomethasone (Qvar)
3) Budesonide (Pulmnicort)
4) MOmetasone (Asmanex)
5) Fluticasone (Flovent)
6) Ciclesonide (Alvesco)
7) Methylprednisolone (Solu-medrol)
List 4 routes of administration for corticosteroids
1) Oral
2) Nasal/ oral inhalers
3) IV
4) IM
How can Fluticasone (Flovent) be used?
May be used alone or in combo with other bronchodilators
Fluticasone should be used with caution in what patients?
Patients with hepatic impairment
List 7 side effects of fluticasone
1) H/A
2) Dry mouth
3) Cough
4) Hoarseness
5) Candida infection
6) Adrenal insufficiency
7) Hyperglycemia
What should be taught to patients after admin of Fluticasone?
Rinse mouth after use
Fluticasone / inhaled steroids are NOT for _______ use
Emergency!!
List 2 generic forms of LABA/ ICS combo inhalers available
1) Budesonide/ Formoterol (Symbicort)
2) Fluticasone/ Salmeterol (Advair; AirDuo Respiclick)
List 2 tips for HFA devices
1) Priming needed
2) May use with spacer
List 1 tip for DPI devices
1) Breath-activated (Take deep/ fast breath)
How do leukotriene modifiers work?
AKA: Leukotriene receptor antagonists
Decrease action of leukotrienes which are strong mediators of bronchoconstriction & inflammation
What are leukotrienes used for?
As maintenance therapy ONLY
What route are leukotriene modifiers given & when should they be given?
Oral route; taken at night
Leukotriene modifiers should be used with caution in what patients?
Those with hepatic impairment
List 3 medications considered leukotriene modifiers
1) Montelukast (Singulair)
2) Zafirlukast (Accolate)
3) Zileuton (Zyflo)
What is the black box warning for leukotriene modifiers? Hint: 6
Psychiatric side effects: aggression, depression, agitation, sleep disturbances, suicidal thoughts, & suicide
How does Montelukast (Singulair) work? Hint: 2
1) Inhibits the leukotrienes receptor & stops actions of the leukotriene
2) Stops allergic response which decreases asthma & inflammatory response
List 3 indications for giving Montelukast (Singulair)
1) Asthma (rarely used)
2) Exercise-induced bronchoconstriction
3) Allergic rhinitis
List 3 age limitations for Montelukast (Singulair) use
1) Exercise-induced: 1 tab at least 2 hrs prior for pts 6 yrs & >
2) Seasonal allergic rhinitis: daily, 2 yrs & >
3) Asthma: 12 mos & >
List 3 adverse reactions of Montelukast (Singulair)
1) H/A
2) GI Sx
3) Liver dysfunction
Generally well tolerated
List 5 neuropsychiatric adverse reactions of Montelukast
1) Agitation
2) Aggression
3) Depression
4) Sleep disturbances
5) Suicidal thoughts & behaviors
What should patient education include when taking Montelukast
There is a reduced effect if taken with Phenytoin
How do immunosuppressant monoclonal Ab work? Hint: 2
1) Inhibits IgE binding to IgE receptors on mast cells & basophils (Omalizumab)
2) Other drugs in class target production of eosinophils
What type of therapy are immunosuppressant monoclonal Ab used for?
Adjunctive therapy for moderate to severe asthma
What age ranges are immunosuppressant monoclonal Ab used for?
6 yrs & older
List 4 medications considered immunosuppressant monoclonal Ab
1) Omalizumab (Xolair)
2) Mepolizumab (Nucala)
3) Reslizumab (Cinqair)
4) Benralizumab (Fasenra)
Route of administration for immunosuppressant monoclonal Ab
SubQ
List 4 side effects of immunosuppressant monoclonal Ab
1) Pain at injection site
2) H/A
3) Nausea
4) Fatigue
Black box warning of immunosuppressant monoclonal Ab
Anaphylaxis (< 0.1%)
Medication regimens:
Inhaled Hint: 3
1) Short acting
2) Long acting (maintenance)
3) Categories
→ SABA & LABA
→ SAMA & LAMA
→ ICS
Medication regimens:
Oral Hint: 4
1) Methylxanthines
2) Corticosteroids
3) Leukotriene receptor antagonists (inhibitor)
4) Combos
→ SABA + SAMA
→ LABA + LAMA
→ LABA + ICS
→ LABA + LAMA + ICS
How do mast cell stabilizers work?
Prevent bronchoconstriction by preventing the release of chemical mediators from mast cells
Mast cell stabilizers should NOT be used for Tx of ____ ____
Asthma attacks
What type of therapy are mast cell stabilizers?
Effective long-term therapy
List 1 medication considered a mast cell stabilizer
Cromolyn (Nasalcrom)
List 2 routes of administration of mast cell stabilizers
1) Metered-dose inhaler
2) Nebulizer
List 8 side effects of Mast cell stabilizers
1) Hypotension
2) Sore throat
3) Taste changes
4) Bronchospasms
5) Chest pain
6) Restlessness
7) Nausea
8) Dizziness
List 4 patient education teaching points
1) Rinse mouth after inhalation, esp inhaled steroids
2) Do NOT swallow Tiotropium capsules
3) Proper use of inhaler
4) When to contact provider
List 8 steps for proper inhaler use
1) Shake canister before each use
2)
