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36 Cards in this Set
- Front
- Back
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asthma
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-atopy- genetic susceptibility to produce IgE directed toward common enviornmental allergens
-IgE causes mast cells and lymphoctes to become activated and sensitized when challenged by allergens -hygiene theory |
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pathophysiology of asthma
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-airway obstruction with edema, bronchoconstriction, hypersecretion and inflammation
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chronic inflamm
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-eosinophiles, T cels, mast cells, macrophages, epithelial cells, fibroblasts and smooth muscle cells
-clinical result is chronic airway hyperreactivity (pts can develop much more frequent episodes of bronchospasm) (remodeling of airways with fibrotic tissue, inc smooth muscle leads to bronchospasm) -loss of lung function if inflamm process is not controlled with corticosteroids |
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aerosol delivery devices
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-site specific to enhance therapeutic ratio
-devices: Nebulizers (jet, ultrasonic), metered dose inhalers, dry powder inhalers -must deposit in lungs so particle size is impt (larger than 10mcg -->oropharynx, smaller than 0.5 are exhaled so ideal size is 0.5-5 mcg) |
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Nebulizers
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-jet nebulizers produce an aersol from liquid (albuterol) in a cup connected to compressed O2
-need to have flow rates >6L/min (get most in 1st few min; may need to ass saline & tap sides to get all drug) -ultrasonic nebulizer vibrates liquid above transducer but produces large particles |
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Metered dose inhaler
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-most commonly used
-200-400 puffs -drug in pressurized canister with metering valve; when actuator is pressed it releases a metered dose of drug and propellant -must be shaken and pressed when pt is inhaling! -must be shaken -hold breath -hold 1-2in in front of mouth |
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Spacers and MDIs
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-hollow chambered tube that allows more evaporation of propellant prior to inhalation--> better delivery
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DPIs
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-dry powder inhaler
-must be delivered in a special inhaler -when you inhale fast enough the medicine is release -technique: exhale, put mouthpiece in your mouth, breath quickly (can be a problem) -Diskus, Rotahaler, Turbuhaler |
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Goals of asthma therapy
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1. Control symptoms
2. Prevent exacerbations 3. Maintain lung function as normal as possible 4. Avoid adverse effects 5. Prevent irreversible airway obstruction 6. Prevent asthma mortality |
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questions to ask
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1. how often are they using their pump (2+/wk is not good)
2. has pt ever been in ICU 3. how many times were they treated in the ER or admitted 4. frequent nighttime systems? 5. How many times do they use systemic steroids? |
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short acting B2 agonists SABA
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-used for quick relief as needed
-Albuterol -Bitolterol -Pirbuterol -via nebulizer and MDH -4-8 hrs of bronchodilation -should not be using more than 2x/wk |
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long acting B2 agonists LABA
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-maintenance therapy
-Formoterol -Salmeterol -onset 20 min so NOT for ACUTE attacks -lasts up to 12 hrs -used with corticosteroid!! |
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clinical use of SABA
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-intermittent episodes of bronchospasm
-DOES NOT improve control of asthma -can give via MDI or nebulizer |
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clinical use of LABA
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-long term control for pts with persistent asthma who are already on low or med dose inhaled corticosteroids
-not used with inflamm meds! -good for nighttime symtoms -risks assoc. with long-acting beta agonists--> may inc the risk of asthma related deaths -should not be the 1st med used to tx asthma -do not use to tx wheezing |
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other beta agonists
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-Terbutaline- in emergencies on;y (parenteral)
-Isoproterenol (non selective)-not used -Epinephrine (B and A agonist) has many SE: BP, HR, Arrhythmias, Rebound (comes back) |
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adverse effects of B2 agonists
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-inc HR
-Tremor -Nervousness -Hypokalemia -Tolerance |
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Corticosteroids
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-most effective anti-inflamm agents for asthma
-inhaled preferred method-ICS (use spacer) -MOA: improves responsiveness to B2 agonists; delayed response in actue asthma; improvement of lung function by 3-6wks) |
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inhaled corticosteroids cont
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-preferred for maintenance therapy
-low, med, and high dose regmiens -other ICS: 1. budesonide 2. beclomethasone 3. flucticasone 4. mometasone-easiest to dose in high dose 5. triamcinolone acetonide |
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systemic corticosteroids
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-acute severe asthma and impending severe espisodes
-takes 4 hrs to work -short burst therapy of 3-10 days- may start with IV or po until pts acheives 70-80% of PEF personal best -prednisone -medrol dose pack -long term therapy has significant AE! |
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ICS-adverse effects
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1. oral candidiasis (have pt rinse their mouth out)
2. Dysphonia- change in voice 3. Reflex cough or bronchospasm 4. bone metabolism/osteoporosis 5. disseminated varicella 6. suppression of HPA function 7. altered gluc metabolism 8. linear growth suppression in kids 4. |
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Leukotriene Modifiers
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-LT receptor antagonists
-Zafirlukast - inc hepatotoxiticty -Montelukast (singulair) -used for maintenance of persistant asthma is addition/alternative to ICS: improve PFTS, dec nocturnal symptoms, improve symptoms |
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Cromolyn Na and nedocromil
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-MOA: mast cell stabilization
-avail as nebulizer bad MDI -nontoxic! -similar efficacy to LT antagonists -used for mild to mod persisent asthma |
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Theophylline
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-methylxanthine - 3rd lie tx
-similar to caffeine -MOA: inhibits phosphodiesterase --> bronchodilation enzyme; other antiinflamm effects |
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theorphylline pharm
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-liver metabolism
-short 1/2 live -1-9 yr old have highest clearance and require higher/kg dosing -narrow therapeutic window (5-15 MCG/ML) |
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Theophylline DI and AE
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1, cigarettes and alcohol
2. Phenytoin and barbiturates 3. Erythhrmycin and cimetidine AE: 1. Ha 2. palpitation and tachy 3. Emesis 4. Seizures (wosrt) |
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Xolair (Omalizumab)
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-anti IgE monoclonal AB
-MOA: IgE blocker -subcutaneous -admin Q 2=4 weeks -adults and kids ?12 yrs with moderate to severe asthma poorly controlled by ICS -AW: Pain, HA, URI |
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exercised induced asthma
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-drop in FEV1 of greater than 15% to 20% of baseline (preexercise)
-symptoms occur after 10 min or so of exercise (SABA or LABA) |
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classifying and managing asthma
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Severity:
-impairment -risk of exacerbations requiring oral steroids Control: -how well asthma is controlled based on risk and impairment category -determine changes in therapy |
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step 1 mild intermittent asthma
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-short acting B agonists as needed!
-use of above 2 or more time a week signifies need to consider daily maintenance therapy -reassess pulmonary symptoms and FEV1 frequently -identify and avoid potential triggers |
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step 2- mild persistent
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-preferred tx is low dose inhaled CS and prm inhaled B2 agonist
-reassess frequently for need to inc meds |
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Step 3 moderate persistent
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-preferred tx is med dose ICS or low dose ICS + long acting B agonist such as formoterol or salemterol
-PRM short acting B2 agonist |
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step 4 or 5 severe persistent asthma
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-med to high dose ICS and long ating B2 agonist
-consider omalizumab injections and allergy shots -if needed po oral CS for acute exacerbations -burst therpy -try to maintain on high dose ICS~ -reasses every month |
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risk factors for death due to asthma
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Past history of sudden and severe asthma attacks
Prior intubation Prior ICU admission Recent ED visits Two or more hospitalizations within past year Use of 2 or more canisters of beta2 agonists /month Low SES and urban Psychiatric/ MR and other medical comorbities Current or recent withdrawal from SYSTEMIC Corticosteroids |
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home mgmt
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-mild-mod can be managed at home
-B2 agonists short acting 2-4 puffs every 20 min x 2 and assess peak flow and clinical status |
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1. Good
2. intermediate 3. poor response |
1. no wheezing, or tachypnea and peak flow 80% or better continue B2 agonist q 4 hrs for 48 hrs--> call MD/PA
2. wheezing and dyspnea with PEF 50-79% continue B agonist but call PA/MD THAT DAY for appt and further instructions and add oral steroid burst 3. to Ed ASAP and add oral burst steroid |
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ED and acute asthma meds
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-inhaled B agonist and anticholinergic (ipatropium) via nebulizer
-albuterol neb soln -Ipatropium -systemic CS po or IV -O2 inhaled -monitor FEV1 or PEF, O2 sat and pulse -Severe respiratory distress unresponsive to meds may require intubation and mechanical ventilation |
