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66 Cards in this Set

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Four hallmark symptoms of asthma
Recurrent wheezing
Recurrent chest tightness
Recurrent cough
Recurrent difficulty breathing
Characteristic timing of symptoms that suggests asthma:
Cough at night

Wheezing or chest tightness after exercise

Symptoms worse after exposure to allergens, smoke, pollutants.

Symptoms worse during strong emotions (laughing, crying) and influenced by menstrual cycle
A worsening of asthma symptoms may be seen after:
Viral illness.
What is necessary to make the diagnosis of asthma:
Spirometry.
When is peak flow metering done re: asthma?
For monitoring, not for diagnosis.
What is the cornerstone of asthma therapy?
Inhaled Corticosteroids (ICS). This is the best choice for controller therapy and is needed for all but the mildest asthma.
What are three classes of medications used in asthma for their anti-inflammatory properties?
Inhaled corticosteroids (ICSs)

leukotriene antagonists (LTRAs)

Mast Cell stabilizers
How much of an ICS dose is absorbed systemically?
20%
why is montelukast superior to zafirlukast?
montelukast is not an CYP inhibitor. Zafirlukast is.
What are three classes of medications used in asthma for their bronchodilating properties?
Beta-2 agonists

Anticholinergics

Theophylline
Mechanism of action of theophylline.
Bronchodilator. Prevents the breakdown of cAMP (which causes bronchial relaxation) by phosphodiesterase. AKA phopsphodiesterase inhibitor.
What are two methylxanthine bronchodilators?
theophylline (PO)

aminophylline (IV)
Facts to know about theophylline prescribing.
Different preparations are NOT interchangeable mg to mg.

Blood levels must be monitored.
Clinical uses of anticholinergics (ipratropium and tiotropium)
Maintenance therapy in COPD.

Not used for asthma maintenance. May be used WITH SABAs for acute attacks.
Clinical use of LABAs
Not to be used as monotherapy. Can be used in combination with ICS for long-term control of asthma symptoms.
Rationale for tapering corticosteroid dose:
Long-term use causing adrenal insufficiency.

Expect cause of inflammation to return.
What type of gastric problem is caused by long term corticosteroid use?
Gastric ulcer
Is there evidence to support tapering PO CS dose after asthma flare?
No
Which of the following is not consistent with the diagnosis of asthma:
a) troublesome nocturnal cough
b) cough or wheeze after exercise
c) morning sputum production
d) colds "go to my chest" or take more than 10 days to clear.
c) morning sputum production
How long does it take for clinical effects to be seen from ICS or LTRA therapy?
1-2 weeks.
About prescribing omalizumab
It can be used in asthma that is uncontrolled on optimized conventional therapy. Requires specialty consult.
Assessment of asthma symptoms.
Assess based on last 4 weeks. Severity is based on most bothersome symptom.

Inquire about:
Symptom frequency
SABA frequency
nighttime symptom frequency
What is a normal FEV1/FVC?
70-85%, depending on age. A decrease is seen with aging.
What are criteria for well-controlled asthma or asthma that is intermittent and does not require controller therapy?
Symptoms <=2 days/week
SABA use <=2 days/week
nighttime awakenings <=2/month
no interference with normal activity
FEV1>80% predicted
FEV1/FVC normal
0-1 exacerbation with oral CS/year
Outline asthma controller therapy.
For intermittent asthma, none needed.

Step 2: low dose ICS
OR
mast cell stabilizer, LTRA, or theophylline

Step 3: medium dose ICS
OR
low-dose ICS + LABA
OR
low-dose ICS +
LTRA, theophylline, or zileuton

From here keep increasing ICS dose. Omalzimam can be used in severe persistent asthma in patients with allergies.
T/F: all patients with asthma should have a SABA inhaler.
True.
Name two LABAs
salmeterol

formoterol
Name 3 SABAs.
albuterol

pirbuterol

levalbuterol
Management of an asthma flare.
Oral prednisone at 40-60 mg/day for 5-7 days.

Increased use of rescue therapy.
most common severity of asthma seen in clinical practice
Moderate severe: daily symptoms, daily SABA use, nighttime symptoms >1/week but not nightly and about 2 exacerbations/year.
Findings on exam during an acute asthma or COPD flare:
Hyperresonance from air trapping
Decreased tactile fremitus
Wheeze (expiratory leading to inspiratory)
What is PEF
Peak Expiratory flow. This is measured by a peak flow meter and is used for monitoring.
In well-controlled or intermittent asthma, PEF should be
>80% normal.
Most common reason for an asthma flare:
URI.
Is asthma a reason to limit physical activity?
No.
What are the pulmonary symptoms characteristic of COPD?
Shortness of breath
Cough
Sputum production
What are non-pharmacologic measured to be encouraged in all patients with COPD:
SMOKING CESSATION

Avoidance of noxious agents, reduction of indoor pollution, reduction of occupational irritant exposure

Influenza vaccine annually
Pneumococcal vaccine as needed
What is considered diagnostic of COPD?
FEV1/FVC<70% by spirometry.
About FEV1 in diagnosing COPD.
FEV1 is usually reduced as the disease progresses, but may be normal in early stages.
What interventions are used for all severities of COPD?
Risk reduction

Influenza Vaccination

SABA inhalers for PRN use
Criteria for round-the clock treatment in COPD.
Moderate COPD defined as:

FEV1/FVC<70%
and
FEV1=50-80% of predicted.
Initial round-the clock management of COPD:
LABA, or an anticholinergic, or both
Indication to add ICS to initial COPD management:
More than 3 exacerbations in 3 years.
ID this common trade name drug: Spiriva
tiotropium, an anticholinergic inhaler used for COPD management.
Identify this brand name medication used in COPD maintenance: Advair HFA
LABA and ICS combo inhaler
Identify this brand name medication used in COPD maintenance: Symbacort
LABA and ICS comb inhaler
Identify this brand name medication used in COPD maintenance: Combivent
ipratropium bromide and albuterol (anticholinergic + SABA)
Ipratropium bromide, when used in COPD provides which therapeutic effect:
a) increased mucociliary clearnace
b) reduced alveolar volume
c) broncodilation
d) mucolytic action
c) bronchodilation
COPD encompasses these two conditions
Chronic bronchitis

Emphysema
How is chronic bronchitis diagnosed?
Clinically by:

Excess mucus for 3 or more months/year for 2 consecutive years in the absence of other causes.
What is the pathophysiology of emphysema?
Enlargement of airspaces distal to the terminal bronchiole.
According to GOLD COPD guidelines, what medication is indicated for stages I to IV?
A SABA inhaler for PRN use.

Note, Stage II is mild disease that does not require controller therapy
What is the most appropriate antibiotic therapy for COPD exacerbation in a patient that failed initial treatment?
A respiratory fluroquinolone.
What is the best ABX choice for a 52 year old man with an acute exacerbation of Stage II COPD?
a) azithromycin
b) amoxicillin
c) TMP/SMX
d) levofloxacin
a) azithromycin
What are indications that antibiotic therapy may be needed in COPD flare?
Change in purulence or quantity of sputum.
Four components of the diagnosis of inhalation anthrax:
Dry Cough
Fever
Malaise
Widened mediastinum on CXR
What is the goal of oxygen therapy in COPD?
To ensure adequate oxygenation of vital organs as evidenced by SpO2 of >=90% or PaO2 >=60 mmHg.
Instructions on using oxygen at home.
Use for at least 15 hours/day, NOT just in response to dyspnea.
Definition of an exacerbation of COPD.
Change in a patient's baseline dyspnea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in management.
Treatment of COPD exacerbation:
Use SABA PRN. Add LABA and/or anticholniergic if needed.

Add oral prednisone if FEV1<50% predicted. Consider ICS in non-acidotic exacerbations.
Indications for CXR in COPD exacerbation:
The presence of fever or low SpO2.
Three most common bacterial agents in COPD exacerbation:
S. pneumo
H. influenzae
M. catarrhalis
Atypicals (M. and C. pneumo, legionella) are associated with what percentage of bacterial COPD flares?
10%
Best antibiotic choice for mild or moderate COPD flare:
Doxycycline, which covers DRSP and atypicals.
Best antibiotic choices for severe COPD flare:
Azithromycin or Fluoroquinolone
If a patient reports orthopnea as part of a pulm problem, what should you consider.
90% of orthopnea is cardiac in origin.