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TXP: Pulm/ Tox. And Rheumatology > Week 1: Asthma/Allergic Rhinitis > Flashcards

Week 1: Asthma/Allergic Rhinitis Flashcards

1
Q

Guidelines used for Asthma

A

Global Initiative for Asthma (GINA)

NAtional Asthma Education and Prevention Program: Expert Panel Report (NAEPP EPR-3)

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2
Q

What is asthma

A

disease characterized by eiither INTERMITTENT OR PERSISTENT presence of highly variable degrees of airflow obsturction from airway wall inflammation and bronchial smooth muscle contriction and in some pts, persistent changes in airway structure occur

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3
Q

Etiology of Asthma

A

Race (black and puerto ricans highest prevalence)

60-80% of susceptibility due to genetic factors

genetic predisposition to atopy(genetic to develop allergic diseases) increases risk for asthma significantly, but not all asthmatics have atopy

environmental factors
*soscioeconomicstatus
*exposure to seocnd hand tobacco smoke
*allergen exposure
*urbanization
*RSV infection
*decreased family size(less exposure to pathogens)
*decreased exposure to common childhood infectious agents

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4
Q

Asthma triggers

A

Resp. infections(RSV, rhinovirus, parainfuenza, myobacterium pneumonia, chlamydia
*VIRAL resp. nfections single most significant trigger in children

allergens(airborne pollen, house dust mites, animal dander, cockroaches, fungal spores)

environment(cold air, fog, ozone, sulfur dioxide, nitrogen dioxide, tobacco smoke, wood smoke

exercise, particularly in cold, dry climate

drugs/perservatives: ASA, NSAIDS (COX-inhibitors), sulfites, benzalkalonium chloride, nonselective beta blockers

occupational stimuli: bakers,farmers, spice and enzyme workers, printers, chemical workers, plastics/rubber/wood workers

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5
Q

Clinical Presentation of Asthma

A

patient may have NO SS at time of exam

SYMPTOMS VARY IN INTENSITY AND TIME

Symptoms:
*dyspnea
*chest tightness
*coughing
*wheezing or whistling sound when breathing
*may occur in association w. exercise, laughter, cold air, allergen exposure, or spontaneously

Signs:
expiratory wheezing on auscultation
cry, hackign cough

signs of atopy(Allergic Rhinitis or eczema)
reduced O2 sat.

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6
Q

as far as SS, mor elikely to be asthma if…

A

> 1 type of symptoms (wheeze, sob, COUGH, CHEST TIGHTNESS)
symptoms often worse at night or in th eearly morning
symptoms vary over time and in intensity
symptoms have identifyable triggers

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7
Q

as far as SS, less likely to be asthma if…

A

chornic production of sputum
isolated ocugh with non other respiratory symptoms
sob associated w. dizziness, lightheadedness or peripheral tingling
exercise induced dyspnea w. stridor (high pitched whistle sound most often heard when taking in a breath)

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8
Q

Dx of asthma

A

no single dx test…

2 defining features: patient hx
*respiratory symptoms
*evidence of varibale airflow limitation

physical exam
*often normal, wheezing on fofrced expiration but not unique to asthma

confirm airflow limitation (FEV1/FVC is reduced atleast once)

confirm variation in lung function is greater than in healthy individuals,
ex: excessive bronchdilator reversibility
significant increase in FEV1 or PEF after 4 weeks of controller treatment
excessive diurinal variability from 1-2 weeks of twice daily PEF moinitoring

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9
Q

7 main classess used for management of asthma

A

short acting beta agonists (SABA)
inhaled corticosteroids (ICS)
long-acting beta agonists (LABA)
Long acting muscarnic antogonist (LAMA) aka antiAch
leukotriene modifiers
theophylline
biologics

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10
Q

short acting beta 2 agonists (SABAs)

A

mao: relaxes airway smooth muscles by stimulating beta 2 adrenergic receptors, increases cAMP and antagonizes bronchoconstriction-> bronchdilation

types:
*short acting: onset: 5-15 min
duration: 4-6h
recommended prn > atc

ADR: tachycardia, tremor, shakiness, lightheadedness, cough, palpitations hypokalemia, tachyphylaxis, hyperglycemia

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11
Q

SABAs

ex: Albuterol
dosage forms:
dosing:

A

SABAs

ex: Albuterol

dosage forms:
1.Pressurized inhalation suspension (MDI)
*proair HFA, Proventil hFA, ventolin HFA, authorized generics
2. Inhalation poweder(DPI)
prair respiclick
3.nebulizers (accuneb,albuerol sulfate solution 0.021%,0.042%0.083%, 0.5%)
4. oral syrup, tablet

dosing:
SOB/rescue: inhale 2 puffs q4-6h prn (mdd 12 puffs/day adults
exercise induces bronchsopasm (EIB): inhale 2 puffs 5-20 min prior to exercise

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12
Q

SABAs

ex: Levalbuterol (R-isomer of albuterol)
dosage forms:
dosing:

A

SABAs

ex: Levalbuterol

dosage forms:
Pressurized inhalation suspension
*Xopenex HFA, GENERICS
2.nebulizer solution
8xopenex solutoin, Levalbuterol HCl sol.

dosing: SOB resuce-inhale 2 puffs q4-6h prn (MDD 12 PUFFS/DAY adults
EIB: 2 puffs 10-30 min before exercise

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13
Q

Inhaled Corticosteroids examples

A

Maintenance Medication!!!!

Ciclesonide
*alvesco-MDI

Fluticasone
*proprionate- (FLovent Diskus/HFA, Advair Diskus/HFA, Wixela Inhub (generic)(combo))-DPI/MDI
*proprionate-(Airduo respiclick and authorized geenric)-DPI (combo)
*furoate-(arnuity Ellipta, Breo Ellipta (combo))-DPI

BEclomethasone
*QVAR-MDI

Mometasone
*Asmanex Twishaler-dpi
*ASMANEX hfa-mdi

Bedesonide
*pulmicort flexhaler-DPI
*pulmicort respules-nebulizer

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14
Q

ICS ROLE IN asthma therapy

A

most effecive anti-inflammatory medications for persistent asthma… 1st line

  1. reduce chornic airway inflammation

reduce risk of exacerbations

improve lung funciton

reduce symptoms

improve QOL

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15
Q

ICS adverse effects

A

ICS AE diminished due to decreased systemic absorpption buttt…

Most common side effect: oral candidiasis (thrush) and dysphonia (horse voice).
*occurs in 30% ofpts. councel to rinse mouth and spit after use. can use spacer/chamber for MDIs.

hyperglycemia, increased risk of factures at higher doses

growth concerns in young children (reduce growth on average cm/year @higher doses

use lowest effective dose: step down dose when asthma is well controlled

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16
Q

ICS considerations

A

ics monotherapy used as controller therapy

avoid use in acute bronchspasm and status asthmaticus

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17
Q

General ICS product considerations

A

avoid dpi IN children <4 Y.O

MDI’s should usuallybe shaken

DPIs should never be shaken

DPI’s should be avoided in those w. milk protein allergeis (budesonide dpi IS AN EXCEPTION)

CPI’d may contain lactose

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18
Q

ICS products

name: Ciclesonide (Alvesco)

available dose:

frequency:

total daily dose intensity category:
Low:
medium:
high:

considerations:

A

ICS products

name: CICLESONIDE (alvesco)

available dose: 8- mcg, 160 mcg

frequency: BID dosing

total daily dose intensity category:
Low: 80-160 mcg
medium: 160-320 mcg
high: >320 mcg

considerations:
activated in lung. good alternative for pts who experience frequent trhush/horsness from other ICS.

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19
Q

ICS products

name: Fluticasone Products

available dose:

frequency:

total daily dose intensity category:
Low:
medium:
high:

considerations:

A

ICS products

name: Fluticasone (Flovent, Arnutiy, Armon Air)

available dose(mcg):
Fluticasone Propionate(Flovent Discus or HFA)
HFA: 44, 110, 220
Diskus: 50,100,250

Fluticasone Proprionate (Armon Air respiclick)
available dosing(mcg): 55,113,232

Fluticasone Furoate (Arnuity Ellipta)
available dosing: 100 mcg, 200mcg

frequency:
Flovent: BID
Armonair:BID
Arnuity Ellipta: QD

total daily dose intensity category:
Proprinonate:
Low:100-250
medium:>250-500
high:>500

furoate:
low:100
medium;100
high:200

considerations:
*proprionate vs furoate; furoate has higher affinity to glucocorticoid receptors
*fluticasone products have higher risk of sore throat/horseness compared to other ICS products

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20
Q

ICS products

name: Beclomethasone

available dose:

frequency:

total daily dose intensity category:
Low:
medium:
high:

considerations:

A

ICS products

name: Beclomethasone (QVAR Rdihaler)

available dose:
MDI:40,80mcg

frequency: BID

total daily dose intensity category:
Low: 100-200
medium:>200-400
high:>400

considerations:
*smaller inhaled particles lead to better lung penetration when compared to other ics

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21
Q

ICS products

name: Mometasone (Asmanex)

available dose:

frequency:

total daily dose intensity category:
Low:
medium:
high:

considerations:

A

ICS products

name: Mometasone (Asmanex)

available dose:
MDI (HFA): 100,200
DPI (Twisthaler): 110, 220

frequency: QD-BID

total daily dose intensity category:
DPI: depends on dpi devide, see product info
MDI..
Low:200-400
medium:200-400
high:>400

considerations:
qd dosing, administer in evening

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22
Q

ICS products

name: Budesonide

available dose:

frequency:

total daily dose intensity category:
Low:
medium:
high:

considerations:

A

ICS products

name: Budesonide (pulmicort)

available dose:
DPI(flexhaler): 90, 180
Nebulizer: 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

frequency: QD-BID dosing

total daily dose intensity category:
Low:200-400
medium:>400-800
high:>800

considerations:
*only ICS available as a nebulizer
*nebulizer prefferedin in children <4

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23
Q

Long acting Beta 2 agonists (LABAs)

MOA:
EXAMPLES:
inhalation kinetics:
duration:
considertions

A

moa: same as SABAs

FDA approved for asthma:
Salmeterol (Serevent)
Formoterol (not available as single agent)
Vilanterol (not availableas single agent)

inhalation kinetics:
onset of bronchdilation
salmeterol: 15-30 min
formoterol (as symbicort): w.in 5 min

duration: drug dependent

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24
Q

LABAs role in asthma therapy

A

considerations:
*LABAS not to be used as monotherapay in asthma
*Formoterol/ICS combos now recommended as PRN/reliever per GINA guide for asthma prevention as early as step 1 and management
*other ICS/LABA combos recommnded as step up therapy beginning w. step 3 (GINA)

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25
Q

LABA black box warning

A

increased risk for asthma related death when used as monotherapy

LABAS should only be used in asthmatics as adjuntive therpay when in combo w. inhaled corticosteroid

monotherapy w. LABA may cause respiratory related death

effect not seen in monotherpay in copd

BBW does not apply to LABA combo therapies.

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26
Q

ICS/LABA combo Products

A

Budesonide/Formoterol (Symbicort)
MDI:1-2 PUFFS BID
dosage: 160/4.5, 80/4.5
considerations:
discard 3 mo. after removal from foil pouch
also labeled for COPD
may be used as rescue therapy/PRN due to short onset

othersss

Fluticasone Proprionate/salmeterol (Advair/Wixela[generic])
Fluticasone proprionate/ salmeterol (Airduo respiclick)
Fluticasone furoate/ Vilanterol (Breo Ellipta)
Mometasone/ Formoterol (Dulera)
*even tho this is an ics/formoterol combo mentioned in GINA guidelines, budesonide is the on that has been studied, and is preffered

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27
Q

LONG acting muscarinic antagonists (LAMAs)

A

MAINTENANCE therapy

moa: inhibit action of Ach @m3 muscarinic receptors in bronchial smooth muscle-> bronchdilation

fdafda labeled for asthma: Tiotropium(spiriva)

inhalation kinetics
onset bronchodilation: w.in 30 min
duration >/24 hrs

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28
Q

Tiotropium (Spirive Respimat)

A

LAMA
strengths: 1.25 mcg
2 inhalations once daily
higher dose for COPD

*may be beneficial to add on for still uncontrolled asthma in pts ona medium-high dose ICS+LABA (step 4 gina)

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29
Q

Oral therapies

Leaukotreine Receptor Antagonists (LTRAs)

A

maintenance medications for persistent asthma

MOA: block proinflammatory leukotreins at receptor sites to reduce airay constriction and mucous secretion

ex: Leukotrein D4 antagonists
*montelukast (singulair)
*zafirlukast (accolate) only indicated for asthma

5-Lipooxygenase inhibitor
*decrease leukotreine production
*zileuton (zyflo): only indicated for asthma

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30
Q

LRTAs role i therapy

A

non preffered therapy
alternative theray in step 2 GINA guidelines
ass on in steps 3 and 4 GINA guidelines

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31
Q

Montekulast (singulair)

A

dosed based on age: >/15 y.o 10mg QPM

allergic rhinitis: same
EIB: 10 mgtaken 2 hrs before exercise, no more than once q24hr

ae: headahce, uppeR RESPIRATORY INFECTIONS, gi n/v/d,

PSYchiatric changes: aggressive behavior, altered mood/mental status, suicidal thoughts.
BBW: risk for depression and suicidal thoughts

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32
Q

MEthylxanthines-Theophylline

A

moa: blocks PDE, increasing levels of cAMP, causing releas of epinephrine form adrenal medulla cells, resulting bronchodilation, cns and cardiac stimulation, diuresis, gastric acid secretion

caution in pts w. cvd, hyperthyroidism, PUD, and seizures

active metabolits: caffeine, 3-methylcanthine

AE: Nnausea, loose stools, ehadache, tachycardia, insomnia, tremor, nervousness O(like caffeine)

considerations:
narrow TI
concentraitons need ot be monitored

target conc: 5-15 mcg/mL

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33
Q

Biologic therpapies for asthma

A

add on therapy for pts w. severe alergiic or eosinophillic asthma

targets : IGE: inihibt ige
inhibit IL-4 , IL3

mostly administered in health care setting

ex: omalizumab
Mepoliumab
Reslizumab
Bnralizumab
Dupilumab

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34
Q

Miscellaneous agents for asthma

A

cromolyn-mast cellstabilizers

Asthmanefrin: OTC epinephrine
*nonselective beta and alpha agonists. AVOID. can cause bronchconstriction and CV AE

systemic corticosteroids: used in seevre asthma. can cause systemic side effects such as hyperglycemiz, increased appetite, insomnia/nervousness, osteoporosis, growth retardation, immunosupression, HPA axis supression

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35
Q

counseling points in general for respiratory devices

A

wash hands w. soap and water befoe use

take a deep breath and exhale completely before accutating the inhaler

after dose inhaled, hold breath for 10 seconds or as long as comfortable, then rbeath out slowly

if more than one inhalantion is required. wait 1-2 min btw doses

if inhaler ocntaines ICS, rinse out mouth or brush teeth immediately after administration to prevent oral candidiasis (thrush)

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36
Q

MDI

A

aerosolized drug delivered by actuating in haler

requires coordination of breath and actuation

hand-breath coordination can be difficult in children, and even some adults. can be overcome by using a spacer/holding chamber

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37
Q

MDI counseling

A

usually require shaking and priming
prime w. 1-2 sprays upon first use or if it has been a while since last use

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38
Q

spacer/holding champer

A

reduced need for hand-breath coordination

best for oyung children

can reduce risk of oral candidiasis when used with ICS

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39
Q

Take home points for different inhalers

A

MDI:
*required hand-breath coordination
*use spcare for small childrem
*requires priming and shaking

DPI:
*no need tocoordinate breath
*requirs forceful inspiration (avoid in children <4)
DO NOT SHAKE

Soft mist inhalers
*Less hand-breath cooridnation vs mdi
less forceful inspiration vs dpi
REQUIRE PRIMING

Nebulizer
*no need to coordinate breath
*must sit and breath through device until medication is gone

40
Q

Assessing Asthma Severity

A

Mild: controlled by Step 1 or 2 trtment strategy
Moderate: controlled by step 3 or step 4 treatment strategy
severe: controlled by step 5

assessed retrospectively fromlevel of treatment required to control treatment and exacerbations

only assessed after pt has been on controller treatment for several months (2-3 months)

PTS ASTHMA MUST BE CONTROLLED W. THERAPY BEFORE ASSESSING ASTHMA SEVERITY

41
Q

chronic asthma control assessment 2 domains

A
  1. symptom control
    2.risk factors for exacerbations and poor outcomes
42
Q

chronic asthma symptom control assessment

A

in the past 4 weeks, has the pt had….

1.daytime asthma symptoms more than twice/week
yes. no.

  1. any night waking due to asthma
    yes. no
  2. relieve SABA symptoms more than twice/week not related to EIB use
    yes.no

4.any activity limitation due to asthma(missing things like work and school)
yes. no

well controlled:none of these
partly controlled:1-2 of these
uncontrolled: 3-4 of these

43
Q

risk for exacerbations

A

medicaitons: ics not prescribed, poor adherance,incorrect inhaler technique, high SABA use

comborbidites, obesity, chornic rhinosinitis, GERD, cofirmed food allergy, anxiety, depression, pregnancy

exposures: smoking, allergen exposure if sensitzed, air pollution

setting: major socioeconomic problems

lung function: low FEV1 esp, ifless than <60% predicted, higher reersibility

other: sputum, blood eosinophils, elevated feno IN ALLERGIC ADULTS ON ICS
EVER BEING intubated in an ICU FOR ASTHMA
having 1 or mroe exacerbatio inlast 12 months

44
Q

goals of long term asthma management

A

symptom control

risk reduction

45
Q

ASTHMA MANAGEMENT Therapy Selection

A

2 tracks

  1. Controller and Preffered Reliever Track
    (ICS-formoterol as reliever) aka MART track (maintenance and reliever therapy)
    PRN ICS-FORMOTEROL IS THE RELIEVER IN TRACK1*

A)Step1-2: PRN dose ICS-formoterol
B)STEP3:low dose maintenance ICS-formoterol
C)STEP4: Medium dose maintenance ICS-formoterol
D)STEP 5: Add on LAMA(refer to phenotype assessment).Consider high dose ICS-formoterol
PRN ICS-FORMOTEROL IS THE RELIEVER IN TRACK1*

  1. Controller and alternative reliever track
    PRN SABA IS THIS RELIEVER IN THIS TRACK*

A)Step1: take ICS whenever SABA taken
B)Step 2: Low dose maintenance ICS
C) Step3: Low dose maintenance ICS-LABA
D) Step 4: medium/high dose maintenance ICS-LABA
E)Step 5: Add on LAMA (refer to phenotype assessment). consider high dose ICS-LABA

46
Q

why isnt SABA monotherpy recommended in asthma treatment?

A

*increases risk for severe exacerbations
*prn SABA trains pt to regard it as primary therapy and can leas to adherance issues when a controller inaler is added

ics should be started ASAP after dx because…
it prevents exacerbations and reduces hospitalization and death
*increases pt. long term lung function if on an ICS

47
Q

Asthma management algorithm INITIAL THERAPY

A

First confirm dx, sympto control and modifiable risk factors, comorbidities, inhaler techinque and adherance, pt preferences and goals

INITIAL THERPAPY: Determine based on symptoms

Controller and Preferred reliever track (PREFERRED TRACK)
A. if symptoms occur <4-5 days/ week
STEP1-2

B. If symptoms occur most days or waking w. asthma >/once a week.
STEP 3

C)Daily symptoms or waking w. asthma >/ once a week, and lowlung function
STEP4

D) short course OCS may also be needed for pts presenting w. severly uncontrolled asthma

Controller and alternate relieve track
A) symptoms <2x a month
STEP 1

b)symptoms >/ 2x/month, but <4-5 days a week
STEP2

c) If symptoms occur most days or waking w. asthma >/once a week.
STEP 3

D)Daily symptoms or waking w. asthma >/ once a week, and lowlung function
STEP4

E) short course OCS may also be needed for pts presenting w. severly uncontrolled asthma

!!!!1THEN FLLOW UP IN 1-3 MONTHS!!!!!

48
Q

Asthma Management algorithm adjusting therapy

A

assess symptom controll
A) if well controlled
*maintain therapy; may step down if well controlled 3 months
*may retrospectively assess severity once controlled for several months

B)if partially or uncontrolled
*always check adherance,inhaler technique
*step up 1 step (if the above are not issues
*review trigger management

49
Q

Stepping down asthma therapy

A

asthma control: good controlled maintained for >/3 months

reduce ICS dose by 25-50% at 2-3 months intervals
if current therapy is low dose ICS or LTRA, PRN ICS/formoterol is a step down option

do not completely stop ICS unless needed temporarily to confirm dx

Document plan

50
Q

Non pharm ASthma Interventions

A

avoid tobacco smoke and other triggers if possible

physical activity; encourage while also providing mangement for Exercise induced bronchsopasm (EIB)

avoid meds that worsen asthma such as NSAIDS, BB

remediation o dampness or mold in homes

Sublingual immunotherpay (SLIT)

51
Q

ASthma preventative therapy

A

influenza vaccine and other vaccinations to prevent resp. diseases

covid vaccination

52
Q

Exercise induced bronchospasm

A

drop i FEV1 of >/15% form baseline (pre-exercise)

pretreatment w. SABA or ics-formoterol

warmup b4 exercise,
cover mouth w. scarf/mask in cold weather

pre-exercise reliever should not be ocunted when assessing overall asthma control

53
Q

defin asthma exacerbation

A

progressive increase in SOB, cough, wheezing, or chest tightness and progressive decrease in lung function

54
Q

asthma exacerbation triggers

A

viral respiratory infections
allergens (pollen, fungal)
food allergy
air pollution
seasonal changes (return to school)
poor adherance to ICS

55
Q

factors that increase asthma related death

A

hx of asthmarequiring intubation and mechanical ventilation

hospitalization or ED visit whitin 1 year

curently using oral corticosteroids

not currently using ICS

SABA overuse: >1 albuterol/month

PHM/SH: psychiatric or psychosocial problems, food allergies

poor adherance w. ics ASTHMA MEDICATIONS OR WRITTEN ASTHMA ACTION PLAN

comorbidities: pneumonia, diabetes, arrhythmias after hospitalization

56
Q

tratment goal for exacerbations

A

correct hypoxemia if present

reverse obstruction

reduce relapse

57
Q

Treatment setting for exacerbations

A

self management

primary care: mild exacerbations

ED/ inpt. admission

58
Q

assessment of exacerbations

A

hx:
onset and cause
severity of SS
all medication use

PE:
*vvitals: including techypnea, tachycardia, BP, dry cough and temp. ability to complete sentences, level of conciousness

respiratory xam: use of accessor muscles

resp exams: use of accessory muscles, wheezing, diminished breath sounds, others: cyanosis, hypoxic seizure

need to assess for other conditions and complications.

bjective:
chest xray to r/o other ocnditions
PEF or FEV1 (outpt only)
abg(INPT ONLY) only if FEV1<50%

59
Q

Management of exacerbations in primary care

A

mild-moderate exacerbation (talks in phrases,prefers sitting to lying, not agitates. RR increased. accessory muscles not used. HR 100-120 bpm. O2 sat. 90-95%, PEF>50%
Treatment:
SABA 4-10 puffs by pMDI+spacer, repeat q20 min for 1 hour
+/-
prenisolone: adults 40-50mg, children 1-2 mg/kg, max. 40 mg
+/- controlled o2 if available: target sat 93-95%

Transfer to acute care facility if…
I. worsening mild or moderate exacerbation after treatment
II. Severe exacerbation (talks inwords, sits hunched forward, agitated, RR>30 bpm, Hr >120 bpm, etc)
III. if exacerbation is life threatening (drowsy,confused, or silent chest)

60
Q

Acute Care Management of exacerbation

A

mild-moderate exacerbation (talks in phrases,prefers sitting to lying, not agitates. RR increased. accessory muscles not used. HR 100-120 bpm. O2 sat. 90-95%, PEF>50%
Treatment: (even if pt was treated@ PCP office)
SABA
consider ipratropium bromide
+/- controlled o2 if available: target sat 93-95%
oral corticosteroids

Severe exacerbation(talks inwords, sits hunched forward, agitated, RR>30 bpm, Hr >120 bpm, etc).
SABA
ipratroprium(PREFFERED AGENT in ER)
controlled o2 to maintain sat. 93-95%
oral or IV corticosteroid
consider IV mag
consider high dose ICS

61
Q

Asthma Exacerbation pharm treatments

Drug: SABA

Dose:

Pearls:

A

Asthma Exacerbation pharm treatments

Drug: SABA (albuterol)

Dose: MDI 4-8 puffs q30 min up to 4 hours, then 1-4 hrs prn
**Nebulizer: 2.5-5 mg q20minx3 doses, thenq1-4h prn (realistically 2-4 in inpt. setting)

Pearls:SABA>iprotropium
inhaled+spacer=nebulizer
duration: 2-4 hrs.
must keep track of how many prn doses a pt receieved when admitted to see if the doses can be spaced out the next day (4-6 hrs)

62
Q

Asthma Exacerbation pharm treatments

Drug: Systemic Corticosteroids

Dose:

Pearls:

A

Asthma Exacerbation pharm treatments

Drug: systemic corticosteroids (prednisone)

Dose: 50 mg po daily for 5-7 days

Pearls: po preffered unless comiting, intubated, somnolence:
onset 4 hrs until improvement

63
Q

Asthma Exacerbation pharm treatments

Drug: Oxygen

Dose:

Pearls:

A

Asthma Exacerbation pharm treatments

Drug: Oxygen

Dose: titrate to O2 saturation of 94-98%

Pearls:–

64
Q

Asthma Exacerbation pharm treatments

Drug: Ipratroprium

Dose:

Pearls:

A

OPTIONALAsthma Exacerbation pharm treatments

Drug: Ipratropium

Dose: MDI: 8 PUFFS Q20MIN PRN FOR 3 HRS
NEB: 500 mcg q30min x 3 doses, and then 2-4 hrs prn

Pearls:
ED only.in combo w. SABA shoewed fewer hospitalizations and improvement in PEF/FEV1. dose dependent

65
Q

OPTIONAL Asthma Exacerbation pharm treatments

Drug: Magnesium

Dose:

Pearls:

A

Asthma Exacerbation pharm treatments

Drug: Magnesium

Dose: 2gm IVx1

Pearls: ED only. failure to respond to initial treatment or have persistent hypoxemia, FEV1<25-30%

66
Q

Asthma Exacerbation pharm treatments

Drug: ICS

Dose:

Pearls:

A

Asthma Exacerbation pharm treatments

Drug: ICS

Dose: high dose ICS w.in 1 hr.

Pearls: ED only. can reduce need for admission if systemic steroids not given, if admitted, should be started on or continued. should be given on discharge @ home.

67
Q

Treatment of asthma exacerbation on discharge

A

inhaled ics
Iif not on, add one
if on, step up the dose for 2-4 weeks

ocs
5-7 day total course, reevaulation should occur prior to d/c

reliever:
transition pt back to prn outpt regimen
if iratropium was added in inpt., d/c

follow up w.in 1 week in the outpt setting

68
Q

MEdications NOT to use in exacerbations

A

aminophylline/theophylline

leukotreine receptor antagonist

hydration

high dose mucolytics

antihistamines

chest physiotherapy

sedation

abx

69
Q

covid-19considerations in asthma exacerbations

A

avoid nebulizers to decrease risk of disseminating virus to othr pts and health care professionals

follow strict infection control procedures

70
Q

Monitoring in asthma exacerbations

A

asthma control: PEF, FEV, O2 sat, clinical smtoms, HR

PE: +/- wheezing, accessory muscle use, cyanosis
*clinical pearl: monitor PEF/FEV/HR/O2 qshift. PE daily
maybe more freuently depending on severeity

medication efficacy/toxicity
*control of asthma, as above
steroids: WBC, glucose(monitor daily)
consider short acting insulin if needed
bronchdilators: HR, frequency of use (ATC v. PRN)

71
Q

Allergic rhinitis definition

A

IgE mediated inflammatory response of nasal mucous membrane secondary to inhaled allergenic particles

72
Q

predisposing factors of allergic rhiniits

A

family hx of allergic rhinitis,atopic dermatitis/eczema, or asthma

allergen exposure

heavy exposure to second hand smoke

73
Q

allergens of allergic rhinitis

A

pollen grains(trees, grass, weeds, ragweed)
mold spored
dustmite fecal proteins
animal dander
cockroaches (fecal matter)

74
Q

clinical presentation of allergic rhiniits

A

clear rhinorrhea

sneezing

nasal congestion

postnasap drip

itchy eyes, ears, nose, or palate

malaise/fatigue

pale or bluish discoloration and swelling of nasal mucosa

conjunctivitis/watery ocular discharge

75
Q

classifications of AR

A

temporal (DO NOT USE)
*seasonalperennial, episodic
8difficultot determine

frequency: intermittent or persistent

severity: mild or moderate to severe.

                       Frequency             
                        <4 days/wk. >4d/w
                        <4 wks./yr    >4w/y

Severity

no interfere M M
w. QOL I P

interfere w. M-S M-S
QOL I P

76
Q

allergen avoidance

A

general: avoidance of smoking, minimize use of wood burning stoves and fireplaces

pollens: keep windows/doors closed during pollen season
avoid using fans to draw outside air in
use AC
miinimize outdoor activities
shower and change after outdoor activities

mold: similar recommendations as above, avoid working w. compost, dry soil and raking leaves. remove moldy surfaces from ome
reduce indoor humidityto <50%

dust mites

animals

cockroches

77
Q

other non oharm AR interventions

A

nasal irrigations

adhesive nasal strips

78
Q

pharm therapy for AR conditions

A

1.which symptoms are targeted

  1. prn vs. routine use
  2. which can be combined fo rbetter effect
79
Q

AR treatment

ex: intranasal steroids
moa:
pk:
AE:

A

AR treatment

ex:
moa: reduce inflamation by supressin mediator and cytokine release and recruitment of neutrophils, basophils, eosinophils and mononuclear cells

reduce antigen-induced hyperresponsiveness of the nsasal mucose to subsequent challende by antigen and histamine release

pk:onset 3-5 hrs to 36hrs

AE:headache, dryness, burning, stinging, blood tinged secretions, epistaxis. hpa supression unlikely, hiv pts may have more systemic absorption, growth supression

80
Q

AR indications for intranasal corticosteroids

Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:

A

Congestion: Y
Rhinorrhea: Y
Sneezing: Y
Nasal Itching: Y
Ocular Symptoms: Y

81
Q

AR treatment

ex: antihistamines
moa:
pk:
AE:

A

AR treatment

ex:
moa: competitively antagonizes histamine (H1 receptors to prevent receptor activation

symptoms controlled based on route of aministration (oral vs. intranasal, opthalmic)

most effective when administered prior to allergen exposure:

pk: 1st gen: lipophyllic, cross bbb
2nd gen more favorable se profile (cetirizine ad levocetirizine most sedating)

AE: 1st gen: lipophilic, cross bbb, ach effects and excessive sedation.
Ach AE
changes in appetite and GI discomfort

*caution of use of 1st gen oral antihistamines and anti-ach in elderly pts.can cause urinary retention issues/bph, slowed gi motility, narrow angle glaucoma, combo products

82
Q

AR indications for oral antihistamines

Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:

A

AR indications for oral antihistamines

Congestion: minimal
Rhinorrhea: Y
Sneezing:Y
Nasal Itching:Y
Ocular Symptoms: Y

83
Q

AR treatment

ex: intranasal antihistamines
moa:
pk:
AE:

A

AR treatment

ex: intransal antihistamines
Azelastine (astepro) OTC, Olopatadine (patanase) RX, Azelastine Fluticasone (Dymista) RX

moa:-same as OAH. equal or superior to OAH. INAH>OAH for nasal congestion

pk: rapid onset:: 15-30 min
AE: bitter taste, epistaxis, headache, somnolense, nasal burning.
taste and BID dosing may limit adherence

84
Q

AR indications for intranasal antihistamines

Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:

A

Congestion: Y
Rhinorrhea: Y
Sneezing: Y
Nasal Itching: Y
Ocular Symptoms: N

85
Q

AR indications for opthalmic antihistamines

ex:
moa:
pk:
AE:

A

ex: Ketotifen OTC, Azelastine RX, Olopatadine, Alcaftdadine, Emedastine, Epinatine

moa: relieves conjunctivitis, appropriate as monotherpay or in combo w. oral agents

pk:–

AE: headache, blurred vision, burning/stinging of the eyes, discomfort, bitter taste, pharyngitis

86
Q

AR indications for opthalmic antihistamines

Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:

A

AR indications for intranasal antihistamines

Congestion: N
Rhinorrhea: N
Sneezing: N
Nasal Itching: N
Ocular Symptoms: Y

87
Q

AR indications for decongestants

ex:
moa:
pk:
AE:

A

AR indications for opthalmic antihistamines

ex: Topical (phenylephrine, tetrahydrozoline, Nahazoline, Oxymetazoline).
oral: pseudoephdrine, phenylephrine +combos

moa: sympathomimetic agents that target agrenergic receptors in the nasal mucose to produce vasoconstriction. reduce swollen nasal mucosa and improve ventilation. (systemic and topical

pk:
Topical: applieddirectly to nasal mucosa: rapi onset of action. prolonged use for more than 3-5 days, can cause rebound congestion
Oral: slower onset

AE:topical: rebound congestion
oral: increase BP, use caution in CV pts., avoid use with MAOIs, risk for significant hypertension, cns stimulation, urinary retention

88
Q

cromolyn in AR

A

moa: mast cell stablizer

useful for treating and preventing sinus symptoms (runny nose, stuffy nose, sneezing and itching

AE: sneezing and nasal irritation

slow onset of action, frequent dosing

1st line agent in pregnant and breast feeding pts. available as OTC

89
Q

ipratropium in AR

A

Treatsrhinorhhea (anti-ach) so drying affects help with rhinorrhea

moa: anti-ach

AE: headache, nosebleeds, and nasal dryness

caution use in narrow angle glaucoma, yasthenia gravis, and bladder neck obstructions/BPH

dosing: 2 sprays in each nostril q2-4 x a day

onset of action 15min

90
Q

montelukast in AR

A

symptoms of perineal and seasonal allergic rhinitis

moa: inhibition of the cysteinyl leukotreine receptor

AE: headahce, fatigue, GI upset, nasal congestion, neuropsychiatric events

slower onset, may not achieve full effect until a month after ubse

not a primary therapy for AR

91
Q

other therapies for AR

A

OMALIZUMAB-mAB

immunotherapy

92
Q

AR indications for intranasal cromolyn

Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:

A

AR indications

Congestion: Y
Rhinorrhea: Y
Sneezing: Y
Nasal Itching: Y
Ocular Symptoms: N

93
Q

AR indications for IPRATROPIUM

Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:

A

AR indications for opthalmic antihistamines

Congestion: N
Rhinorrhea: Y
Sneezing: minimal
Nasal Itching: minimal
Ocular Symptoms: N

94
Q

AR indications for Leukotriene receptor antagonist (Montelukast)

Congestion:
Rhinorrhea:
Sneezing:
Nasal Itching:
Ocular Symptoms:

A

AR indications for opthalmic antihistamines

Congestion: minimal
Rhinorrhea:minimal
Sneezing:minimal
Nasal Itching: minimal
Ocular Symptoms:no

95
Q

considerationf for AR treatment

A

INS have superior efficacy, but OAH may be adequate for some pts w. primary symptoms of sneezing and itchingand those w. intermittent symptoms

ins>oah for nasal symptoms (incl congestion

INS(and prob OAH>LTRA

intranasal antihistamines have more rapid onset than INS

short course of systemic cs not shown superior to INS

96
Q

common clinical scenarios in AR

A

if primary symptom is nasal congestion: INS or oral decongestant

INTERMITTENT SNEEZING,nasal itching, and rhinorrhea: (OAH or INAH)

mild symptoms(sneezing and itching intermittent): OAH

moderate severe: INS, INAH, combo therpay

97
Q

considerations for combo therapyin AR

A

if one is not effective, can add another of same route (that ive noticied)

for ex: if INS monotherpay not working, can add INAH , if oral antihistamine not working, can add oral decongestant

however, avoid combination with INS and OAH, no evidence of synergistic effect using them together

TXP: Pulm/ Tox. And Rheumatology (7 decks)

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