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196 Cards in this Set
- Front
- Back
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Cor pulmonale
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right ventricle failure
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Hyperpnea
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abnormally deep breathing
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Hypopnea
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shallow breathing
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Orthopnea
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difficulty breathing in supine position
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Dyspnea
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difficulty breathing
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Hypoxemia
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deficiency of O2 conc. in the blood
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Hypercapnia
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greater than normal amts. of CO2 in the blood
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Acidosis
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inc. conc. of H+ ions & retention of CO2 (pH < 7.35)
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Alkalosis – excess of bicarbonate ions (pH > 7.45). Loss of CO2 & hyperventilation.
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excess of bicarbonate ions (pH > 7.45). Loss of CO2 & hyperventilation.
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Hematocrit
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A measure of the packed cell volume of red cells expressed as a percentage of the total blood volume
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Hemoglobin
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carries O2 to the cells from the lungs and CO2 away from the cells to the lungs
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Upper Respiratory Tract Contains
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Nose
Nasal cavity Paranasal sinuses Pharynx |
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The Pharynx..
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*Conducts air to the lower respiratory tract
*Conveys food to the esophagus |
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Lower Respiratory Tract Contains
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Larynx (voice box)
Trachea (windpipe) Bronchi Bronchioles Alveoli of the lungs |
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The right lung has..
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3 lobes and is higher than the left due to the liver
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The left lung has....
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2 lobes because of the heart
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Goals of COPD
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1.) Smoking cessation
2.) Treatment & Prevention of acute exacerbations 3.) Reduction in rate of progression of disease (stop smoking) 4.) Should receive influenza and pneumococcal vaccinations as standard-of-care |
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What is Chronic Bronchitis
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* Chronic or recurrent excess mucous production with cough
* Cough occurs most days during a 3 month period for at least 2 consecutive years. * < o2 Blue Bloater * Always have condition but symptoms may get better * Acute exacerbations is usually due to an infection |
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What is Emphysema
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* Abnormal Permanent enlargement of the air spaces distal to the terminal bronchiole with destruction of their wall and without obvious fibrosis (loss of elasticity)
* Normal inhalation, difficult exhalation * < CO2 Pink Puffer |
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Age of Emphysema
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60+
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Dyspnea with Emphysema
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Severe
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Cough with Emphysema
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After dyspnea
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Sputum with Emphysema
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Scanty, Mucoid
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Infection with Emphysema
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Less Common
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Resp Episode with Emphysema
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Often terminal
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Chest Film with Emphysema
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Increase in diameter
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PaCO2 with Emphysema
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35-40
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PaO2 with Emphysema
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65-75
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Hct% with Emphysema
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35-45
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Age with Bronchitis
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50+
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Dyspnea with Bronchitis
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Mild
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Cough with Bronchitis
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Before Dyspnea
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Sputum with Bronchitis
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Copious
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Infection with Bronchitis
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Frequent
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Resp Episode
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Repeated
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Chest Film
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Large Heart
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PaCO2
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50-60
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PaO2
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45-60
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Hct%
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50-60
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Rest with Emphysema
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None or Mild
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Cor Pulmonale with Emphysema
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Rare
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Diffusion Cap with Emphysema
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Decreased
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Classification with Emphysema
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Pink Puffers
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Rest with Bronchitis
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Mod-Severe
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Cor Pulmonale with Bronchitis
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Common
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Diffusion Cap with Bronchitis
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Slightly Decreased
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Classification with Bronchitis
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Blue Bloaters
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Acute Respiratory Failure
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* Change in arterial blood gases
* PaO2 < 50mm Hg or a PaO2 dec of 10-15 mm Hg that dec. serum pH to 7.3 or less |
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Most common cause of acute respiratory failure
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acute exacerbation of bronchioles with inc. in volume and viscosity of sputum
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Pathophysiology of Chronic Bronchitis
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1 - Continual Bronchial Irritation
2 - Hyperplasia/Hypertrophy 3 - Tracheobronchial Mucus Secretion 4 - Inflammation, narrowing of lumen, fibrosis 5 - Obstruction (small airway changes) 6 - Hypoxemia which leads to Pulmonary HTN OR Erythropoiesis and Pulmonary HTN leads to Cor Pulmonale |
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Pathophysiology of Emphysema
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1 - Smoking
2 - Macrophage alveolitis which leads to Inc. neutrophils 3 - Dec. Protease inh., Inc. Proteases (elastase) 4 - Lung destruction loss of elastic recoil |
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What happens in the early stages of COPD? (6 things)
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1) Wheezing at rest and prolonged expiratory phase
2) Diminished breath sounds 3) Reduced rib cage expansion 4) Hyperresonance of the lungs 5) Breathlessness 6) Cough (Usually productive of purulent sputum) |
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What happens in the advanced stages of COPD? (7 things)
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1) Pulmonary circulation
2) Right heart (Right ventricular dilation and enlargement may occur resulting in cor pulmonale) 3) Respiratory muscles 4) Persistent alveolar hypoxia 5) Barrel chest 6) Weight loss 7) Hypercapnia |
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Force Expiratory Volume (FEV1) in NONSMOKERS Begins...
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FEV1 in nonsmokers without respiratory disease begins an annual decline at about age 35
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Force Expiratory Volume (FEV1) - rate of loss in non smokers
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normally is about 25-35 ml each year.
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Force Expiratory Volume (FEV1) in smokers...
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* Annual decline in heavy smokers or susceptible people can be up to 100 ml annually
* Although lung function occurs rapidly there is a reserve which delays the onset of symptoms * Symptoms may not occur until age 50 * Dypsnea with effort may not occur until age 60 |
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Diagnosis of COPD - Spirometry
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Involves the measurement of lung volumes and capacities or pulmonary function test.
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Diagnosis of COPD - Chest radiographs
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Not sensitive to detect mild COPD
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Diagnosis of COPD -Arterial blood gases
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Not necessary if stable with no apparent distress (monitor in patients with stage I-II COPD because of hypoxemia)
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Hallmark of COPD &
Severity of COPD |
Hallmark of COPD is a decrease in FEV1 in forced vital capacity (FVC) ratio to below 75% on spirometry
Severity of COPD is usually based on FEV1 findings alone |
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Drugs used in COPD
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* Anticholinergics (Ipatropium, Tiotropium, Atropine)
* Via nebulizer or MDI * Less systemic side effects than that of beta agonist and has greater improvement on PFT’s. |
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anticholinergics used in COPD have a
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Slower onset of action than beta agonist.
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Do NOT use anticholinergics as...
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PRN use as schedule dosing .
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For an acute COPD attack use...
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beta2 agonist (Xopenex has only R isomer which helps avoid heart issues esp. in children).
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For a chronic COPD use...
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Ipatropium and a short acting beta2 agonist as a rescue inhaler.
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If COPD is still not under control use....
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Ipatropium with long acting beta2 agonist (Salmeterol) and a short acting rescue (Albuterol).
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1st drug used in acute COPD attacks
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Beta2 Agonist (Albuterol, Levalbuterol, Salmeterol)
* Use levalbuterol because only has R isomer |
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Another COPD drug
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Methylxanthines (Theophylline)
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Lastly you can also use _________ for COPD
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Glucocorticoids (IV, or inhaled)
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Glucocorticoids used IV
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Methylprednisolone, hydrocortisone, cortisone, dexamethasone
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Glucocorticoids used PO for COPD
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Hydrocortisone, prednisone, methylprednisolone, triamcinolone & dexamethasone
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Glucocorticoids used Inhaled for COPD
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Triamcinolone, beclomethasone & Flunisolide
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Leukotriene Antagonist
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– block the release of leukotrienes in the lungs. Inflammation causes an inc. in leukotrienes, substances that constitute the slow-reacting substance of anaphylaxis (SRS-A)
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Methylxanthines (Theophylline) –
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inc. cyclic AMP to inhibit breakdown of sensitized mast cells that stimulate the release of histamine, serotonin and SRS-A
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Mast Cell Stabilizers –
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inhibit the release of histamine from mast cells to reduce allergic effects
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Sympathetic Agonist –
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stimulate sympathetic systems to decrease mucus secretions & relax bronchial muscle spasms
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Corticosteroids –
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produce an anti-inflammatory effect and reduce mucus secretions & tissue histamine
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Anticholinergic –
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reverse effects of ANS on pulmonary tree and smooth muscle
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Symptoms of Asthma
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1) Breathlessness and tightness of chest
2) Wheezing 3) Dypsnea 4) Cough |
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Test for lung function in Asthma
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1) Forced expiratory volume (FEV)
2) Peak expiratory flow rate (PEFR) |
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Exercise Induced Bronchospasm
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1) Starts immediately after exercise
2) Peaks in 5-10 minutes 3) Resolves in 20-30 minutes 4) Use beta2 agonist immed. Before exercise or Cromolyn inhaled 15 min. before exercise prophylacticly. |
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Step 1 Mild Intermittent Asthma
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1) Treated on a PRN basis. No long term meds are needed.
2) Acute attacks treated with a short acting beta2 agonist. 3) If needed < twice weekly; nocturnal sx < 2 x mo; PEF/FEV > 80% predicted, PEF variability < 20% go to step 2 |
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Step 2 Mild Persistent Asthma
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1) Long term control
2) Quick-relief a. 1st Long term control low dose with glucocort. and with beta2 agonist. b. 2nd cromolyn and leukotriene rec. antagonist 3) Sx > 2 x wk, nocturnal sx > 2 x mo, PEF/FEV > 80% predicted, PEF variability 20-30% |
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Step 3 Moderate Persistent Asthma
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1) Inhale medium dose glucocort or low dose glucocort with long-acting inhaled beta2 agonist (Salmeterol) with short acting beta2 agonist
2) Low dose glucocorticoid a. Leukotriene receptor antagonist b. Theophylline SR c. Long-acting beta2 agonist 3) Sx daily, nocturnal awakenings at least 1 x wk, PEF/FEV > 80% of predicted PEF variability > 30% If pt is using short acting beta2 agonist once daily move to step 4 |
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Step 4 Severe Persistent Asthma
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1) High dose inhaled glucocort. w/ long-acting beta2 agonist. If needed an oral glucocort. can be added and for breakthrough add short acting beta2 agonist
2) May try step down tx once sx are managed 3) Continuous sx, frequent nocturnal awakenings and exacerbations, PEF/FEV < 60% predicted PEF variability > 30% |
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Acute Severe Exacerbations in Asthma
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1) Hospitalization may be required. Use nebulizer or mdi beta2 agonist
2) If pt. is unconscious or cannot generate PEFR SQ Epi should be given 3) If no response to beta2 agonist a glucocort (IV methylprednisolone or PO prednisone) should be given 4) Maintain O2 saturation above 95% |
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Zone System for Monitoring Tx
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Green, Yellow and Red zone
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Green Zone
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Pt has no Sx and has a PEFR greater than 80% of their personal best. Control is good
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Yellow Zone
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Beta2 agonist if this does not work use a short course (4 days) of oral glucocorticoid.
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Red Zone
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Sx occur at rest or interfere with activities and PEFR is less than 50% of personal best.
Beta2 agonist inhaled immed. if remains below 50% seek medical attention. |
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Most asthma drugs are given...
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via inhalation
1) Delivers drug directly to site 2) Systemic effects are minimized 3) Relief of acute attack is rapid. |
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3 kinds of inhalation devices
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Inhalation Devices
1) Metered-dose inhalers a. Chlorofluorocarbons (CFC’s) b. Hydrofluoalkane (HFA’s) 2) Dry-powder inhalers 3) Nebulizers |
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Metered-dose inhalers (MDI)–
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Releases a fixed amount of drug with each actuation
Only 10% reaches the lungs (use spacers esp. with glucocorticoids) Chlorofluocarbons (CFC’s) Hydrofluoralkane (HFA’s) |
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Dry-powder inhalers (DPI)
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Delivers dry micronized powder directly into the lungs
No propellant is employed Delivers more drug into the lung 20% |
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Nebulizers
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– Converts drug soln. into a mist much finer than produced with inhalers
Some beta2 agonist may not work as an inhaler because drug will be delivered slower, bronchioles dilate slowly and gains deeper access. |
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Drugs for Asthma - 2 main classes
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1) Anti-inflammatory agents (glucocort. & Cromolyn)
2) Bronchodilators (beta2 agonist) |
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Drugs for Asthma - other classes
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1) Methylxanthines
2) Anticholinergic 3) Leukotriene modifiers 4) Monoclonal antibody |
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Glucocorticoids for Asthma
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Most effective (inhalation, PO, IV)
Used on a fixed schedule not PRN |
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Glucocorticoids for Asthma (what do they do to inflammation, synthesis & Infiltration)
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* Suppresses inflammation reducing bronchial activity
* Decreases synthesis and the release of inflammatory mediators (leukotrienes, histamine, prostaglandins) * Decreased infiltration & activity of inflammatory cells (eosinophils, leukocytes) |
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Glucocorticoids for Asthma (what do they do to edema & airway mucus)
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* Decreased edema of the airway mucosa (secondary to a dec. in vascular permeability)
* Decrease airway mucus production and inc. the number of beta2 rec. as well as their responsiveness to beta2 agonist. |
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Inhaled Glucocorticoids
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1st line Tx used in pts. w/ moderate-severe asthma used daily not PRN.
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6 glucocorticoids for Asthma
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1) Beclomethasone (QVAR, Beconase) HFA
2) Budesonide (Pulmicort) Nebulizer and DPI 3) Flunisolide (Aerobid) *CFC 4) Fluticasone (Flovent) HFA 5) Mometasone (Asmanex) DPI 6) Triamcinolone (Azmacort) *CFC |
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If it is a CFC...
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use a spacer device
A) Increased amount of drug delivered to site B) Reduce amt. deposited in oropharynx C) HFA do not need spacer b/c the drops deposited are much smaller |
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What should you use before a glucocorticoid?
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****Using Beta-2 agonist 5 min. BEFORE using a glucocort so it can penetrate deeper into the lungs.****
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Precautions/Adverse Effects of Glucocorticoids... ( 7 things)
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Even at high doses adverse effects are minimal but watch for adrenal suppression and bone loss.
1) Use lowest dose possible 2) Intake adequate amount of Ca+ & Vit D 3) Participate in weight bearing exercise 4) May slow growth in children 5) Prolonged use can cause glaucoma and cataracts 6) Gargle after use and/or use spacer to avoid oropharryngeal candidiasis & dysphonia. 7) Hyperglycemia |
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Oral Glucocorticoids
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1) Prednisone, Prednisolone, Fludrocortisone (Florinef)
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Reserve oral glucocorticoids for...
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pts. w/ severe asthma
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Use briefly...
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for acute uncontrolled asthma at high doses for short periods of time.
Withdraw tx use tapering dose May retard bone growth. Caution in pts. with diabetes (esp. during long term use) Increased risk for peptic ulcer disease |
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Adverse effects of oral glucocorticoids
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1) Adrenal suppression
2) Sodium retention and potassium loss (Florinef) 3) Osteoporosis 4) Hyperglycemia 5) Peptic ulcer dz. 6) Suppression of growth in young people |
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Prednisone MOA
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Decreased inflammation by suppression of migration of leukocytes and reversal of increased capillary permeability
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Prednisone Pharmacokinetics
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Hepatically metabolized
Half-life 2.5-3.5 h Inhalation only for chronic use not PRN Taper oral dose if use for longer than 2 weeks Take in the morning with food |
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Prednisone > effect toxicity
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Use of NSAIDS may increase GI ulceration
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Prednisone < effect toxicity
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Barbiturates
Phenobarbital Rifampin Salicylates Vaccines |
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Bronchodilators
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Albuterol, Epinephrine, Formoterol, Isoetherine, Isoproterenol, Levalbuterol, Metaproterenol, Pirbuterol, Salmeterol, Terbutaline
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Albuterol: Adrenergic rc, Isoproterenol
(min), DOA (hours) |
Beta 1 < Beta 2, < 5, 3-8
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Epinephrine: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Alpha, Beta 1 & 2, 1-5, 1-3
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Formoterol: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Beta 1 < Beta 2, 3-5, 12
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Isoetherine: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Beta 1 < Beta 2, < 5, 1-3
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Levalbuterol: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Beta 1 < Beta 2, 10-17, 5-6
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Metaproterenol: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Beta 1 < Beta 2, 5-30, 2-6
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Pirbuterol: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Beta 1 < Beta 2, < 5, 5
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Salmeterol: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Beta 1 < Beta 2, 5-14, 12
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Terbutaline: Adrenergic rc, Isoproterenol (min), DOA (hours)
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Beta 1 < Beta 2, 5-30, 3-6
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What does a Beta2 Agonist do?
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* > Heart rate (esp. if non-selective beta agonist)
* > Blood pressure (esp. if non-selective beta agonist) * RBC’s pour into the circulation from the spleen * Blood flow shifts to skeletal muscle * > Blood glucose * Bronchioles and pupils dilate |
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Nonselective Epinephrine
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* Bronkaid Mist, Primatene Mist
* Bronchial asthma, bronchitis, prevention of bronchospasm |
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Nonselective Epinephrine - Pharmacokinetics
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* Inhalation onset 3-5 min, SQ 6-15 min, IM variable
* Duration 1-3 hours * Maximum 12 inhalations/24 hours * Metabolized at sympathetic nerve endings * Excreted in kidneys |
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Nonselective Epinephrine Important info for person taking..
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* Do not administer epi. and other beta adrenergic agents concurrently, allow 4 h between doses
* Teach pt. to take pulse rate before inhalation tx * Relief within 20 min. * Emergency self inject with epi. SQ |
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Nonselective Beta Agonist Isoproterenol
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Bronchial asthma, bronchitis, emphysema, (cardiac arrest, AV block)
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Nonselective Beta Agonist Isoproterenol - Pharmacokinetics
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* inhalation onset 2-5 min., SL 15-30 min, IV immediate
* Duration 0.5-2 hours * Metabolized in the liver, lungs * Excreted by the kidneys |
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Nonselective Beta Agonist Isoproterenol - Pharmacodynamics
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* beta 1 and beta 2 agonist, main action on bronchial smooth muscle and heart,
* > blood glucose |
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Isoproterenol - CAUTION
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* arrhythmias, coronary insufficiency, HTN, hyperthyroidism, diabetes
* Allow 1-5 min between inhalations * Rinse mouth after use * Do not use if a precipitate or discoloration occurs in vial. |
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Inhaled Short Acting Beta2 Agonist - 4 kinds
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* Albuterol (Proventil HFA, Ventolin HFA, ProAir HFA)
* Bitolterol (Tornalate) * Levalbuterol (Xopenex nebules, Xopenex HFA) * Pirbuterol (Maxair) |
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Inhaled Short Acting Beta2 Agonist (3 things)
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1) Effect almost immed. & persist up to3-5 hours. Long acting persist up to 12 hours.
2) Taken PRN or for exercise induced asthma 3) For severe acute attack use a nebulizer (MDI can still be very effective) |
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Inhaled Short Acting Beta2 Agonist - Adverse Effects
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Generally well tolerated (tachycardia, angina & tremor)
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Albuterol - MOA
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* Beta 2 specific
* Stimulates enzyme adenyl cyclase to produce cyclic 3’5’ AMP relaxing smooth muscle of bonchi, uterus and blood vessels. |
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Albuterol - Pharmacokinetics
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* 1-2 puffs q 4-6 hours
* Inhalation onset 5-15 min, PO 15-30 min * Duration 3-6 hours * Hepatically metabolized * Excreted kidneys, feces |
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Albuterol - Drug Interactions
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* Similar to Isoproterinol
* MOAI * Epinephrine * Other inhaled sympathomimetics * Tricyclic antidepressants |
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Albuterol Management
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* Smoking cessation
* Avoid caffeine * Foul taste will gradually disappear * Rinse mouth after inhalation * Excessive use may cause paradoxical bronchospasm * Do NOT add OTC drugs to regimen, NO OTC (Primatine Mist, Bronkaid Mist) * Report: chest pain, extreme dizziness, severe headache, palpitations, tachycardia, HTN |
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Inhaled Long Acting Beta2 Agonist (2 kinds)
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* Formoterol (Foradil Aerolizer) – Works w/n 1-3 min.
*Salmeterol (Servent Diskus) – Works w/n 10-30 min. 1) Dosing done on a fixed schedule not PRN. 2) They are NOT 1st line of tx and should NOT be given alone but given in combo with glucocorticoid |
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Oral Beta2 Agonist (2 kinds)
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* Albuterol (Proventil, Volmax)
* Terbutaline (Brethine) Only used for long term control because effects are too slow. Are NOT 1st line tx Should not be used alone |
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Oral Beta2 Agonist - Adverse Effects
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1) Selectivity is not 100% and will still activate some beta1 rec. in the heart. Pt. should ALWAYS report chest pain and inc. heart rate.
2) Can cause tremor by stimulating beta2 rec. in skeletal muscle and will dec. with inc. use. |
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Combo Glucocort/Beta2 Agonist
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* Fluticasone (glucocort) & Salmeterol (long-acting beta2 agonist) is in Advair Diskus (DPI)
* Approved for maintenance in adult and children at least 12 years of age. * Make sure pt. understands how to use * Make sure to tell pt. that there is no taste (Some pts. will continue activating device because they think they are not receiving medication because there is no taste) |
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Cromolyn (Mast Cell Stabilizer)
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Cromolyn (Intal), Nedocromil (Tilade MDI), Nasalcrom nasal spray
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Cromolyn (Mast Cell Stabilizer) - MOA
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* Inhibits release of mediators from mast cells including histamine and < number of eosinophils
* Prophylactic use not acute attack. Reduces frequency/severity of attacks. * It suppresses inflammation by stabilizing the mast cell cytoplasmic membrane preventing the release of histamine, eosinophils, macrophages & other inflammatory cells * It is NOT a bronchodilator |
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Cromolyn Sodium - Pharmacokinetics
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* Only 8% absorbed by the lungs, no systemic effects & unchanged in the urine.
* Onset of action 15 minutes * Duration 4-6 hours |
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Cromolyn Sodium - Contraindications
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* Do not use in acute attacks
* Impaired hepatic/renal function |
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Cromolyn Sodium Management
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* > fluid intake
* Take at regular intervals * Takes 2-4 weeks for full effect * Not for acute attack * Use with steroid inhaler |
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Anticholinergics ( 2 kinds)
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* Ipratropium (Atrovent HFA, Combivent & DuoNeb)
* Tiotropium (Spiriva) Long acting * Act through blockade of muscarinic receptors in the bronchi causing bronchodilation. ACh antagonist |
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Ipatropium Pharmacokinetics
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* 2 puff qid (max 12 puffs/24 h)
* Inhalation onset 15 min, peak 1-2 h * Not for occasional use; do not change dose * Duration 3-6 h * Half-life 2 h |
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Ipatropium Bromide - Adverse Effects
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Cough, Nervousness, dry mouth, hoarseness
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Ipatropium Bromide - Contraindications
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* Hypersensitivity to atropine and peanuts
* Glaucoma * Bladder neck obstruction * Pedi safety < 12 y/o not established |
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Metylxanthines ( 2 kinds)
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1) Theophylline (Theo-24, Uniphyl)
2) Aminophylline (Truphylline) Asthma, chronic bronchitis, emphysema |
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Metylxanthine - MOA
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* Blocks phosphodiesterase which inc. tissue concentrations of cAMP which stimulates catecholamine stimulation of lipolysis, glycogenolysis and gluconeogenesis and induces release of epi.
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Theophylline has a....
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narrow Tx range, given orally, NO effect by inhalation
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Theophylline - Pharmacokinetics
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* onset 30-60 min.
* Half-life adults 8 h, pedi 4 h * Duration 24 h * Hepatically metabolized to caffeine * Excreted by kidneys |
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Theophylline - Adverse Effects
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* Life threatening – respiratory arrest, ventricular tachycardia
* Common – tachypnea, palpitations, sinus tachycardia, nervousness, restlessness, insomnia, anorexia |
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Theophyllilne Factors > therapeutic effect
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* Age
* Erythromycin, cimetidine, ciprofloxacin * Disease – cirrhosis, pulmonary edema, CHF, severe COPD |
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Theophyllilne Factors < therapeutic effect
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* Adolescence
* Phenobarbital, phenytoin, tobacco, marijuana * High protein diet |
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Theophylline - Contraindications
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* Hypersensitivity
* Peptic ulcer disease * Cardiovascular disease * Seizure disorder |
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Theophylline - management
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* > Fluid intake to < secretion viscosity
* Smoking cessation * Serum drug levels q 6-12 mo if asymptomatic |
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Theophylline - overdose
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* No known antidote
* < drug absorption, activated charcoal, gastric lavage |
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Leukotriene Modifiers
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Suppress effects of leukotriene and decrease bronchoconstriction, inflammation, edema, mucus secretion and recruitment of eosinophils.
1) Zileuton (Zyflo) 2) Zafirlukast (Accolate) 3) Montelukast (Singulair) 4) Amalizumab (Xolair) |
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Zileuton (Zyflo)
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* Blocks leukotriene synthesis
* Prophylactic tx not for acute attack * Is metabolized by CYTP450 so if combined with theophylline can increase theophylline levels (can also inc levels of warfarin & propranolol) * Use in adjunct with glucocort. or beta2 agonist * Can cause liver damage and inc levels of alanine aminyltransferase (ALT) activity |
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Zafirlukast (Accolate)
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– Anti-inflammatory leukotriene rec. antagonist which dec. bronchoconstriction but is less effective than beclomethasone
* Approved for maintenance tx for asthma for children 5 yr. and older. * Food reduces absorption by 40% give 1 hr. AC or 2 hr. PC. * Hepatic metabolism so check LFT’s and ALT. * Inhibits CYTP450 (watch theophylline and warfarin levels) |
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Montelukast (Singulair)
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* (tabs, chewable, granules)
* MOA same as Zarfirlukast * Not for quick relief. Taken HS * Approved for pts. over 1 yr. of age * Less effective than inhaled glucocort. * Protein bound and metabolized by CYTP450 * No liver damage, no serious drug interactions (does NOT inc. levels of warfarin or theophylline) |
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Amalizumab (Xolair)
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* Monoclonal antibody
* Rarely used because of anaphylaxis and cancer * Given SQ and may cost $10,000/yr |
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Tuberculosis
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2 billion people infected and kills more people than AIDS and malaria combined.
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Tuberculosis is cause by
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Mycobacterium tuberculosis and may have no sx.. However, when the disease is active morbidity can be high.
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Tuberculosis is transmitted by
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by aerosol taken into the lungs by phagocytic cells and can be transmitted via lymphatic circulation.
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Tuberculosis - the bodies immune system can
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get infection under control but unless receive proper medication can harbor lifelong infection.
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Tuberculosis treatment
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* divided into 2 phases and is long so adherence is a problem.
* 1st the induction phase which renders sputum non-infectious, then last 2 months tx with 4 drugs 1-3 x’s/week |
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Tuberculin Skin Test (TST)
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* Intradermal injection of Purified Protein Derivative (PPD)
* If pt. is exposed to tuberculosis the immune system elicits a response in 48-72 hours * Hardness around injection site and size will determine how aggressive tx should be. * Smaller the size the more aggressive the tx. * 2 or more drugs are used to kill active and resting tubercle bacilli. |
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Tuberculosis Treatment Regimens
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* Drug susceptibility tests on first isolation
* Monitor closely for compliance, adverse rxn, progress or tx program. * Chemoprophylaxis: INH qd x 6 mo; HIV INH qd x 12 mo. * Begin 4 drug regimen |
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4 drug regimen for treatment of tuberculosis
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1) Isoniazid (INH)
2) Rifampin 3) Pyrazinamine (PZA) 4) Ethambutol or Streptomycin |
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Treatment Guidelines - Tuberculosis
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* Multidrug regimens and completion of full course of tx
* Single daily dose preferred * Prolonged tx necessary * Supervised, twice-weekly regimens reasonable alternative for noncompliant * Follow closely to ensure compliance and monitor for efficacy and toxicity * Elaborate programs of rest and diet no longer applicable. |
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Drugs used in Tuberculosis - 1st line drugs
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1) Isoniazid (INZ)
2) Rifampin 3) Rifapentin 4) Rifabutin 5) Pyrazinamide 6) Ethambutol |
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Drugs used in Tuberculosis - 2nd line drugs
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1) Strptomycin
2) Para-aminosalcylic acid 3) Kanamycin 4) Amikacin 5) Capreomycin 6) Ethionamide 7) Cycloserine 8) Levofloxacin, moxifloxacin and Gatifloxacin |
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Isoniazid
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* Highly selective for M. tuberculosis.
* Bacterialcidal to actively dividing mycobacteria. * Bacterialstatic to mycobacteria that are resting. * Drugs that are resistant to INZ are also resistant to ethionamide. * Preferred tx for latent and prophylaxis tb * Single agent for prophylaxis or with other agents against active tb * Tx given over 6-9 months given daily or twice weekly. * PO or IM |
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Isoniazid - how to take
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* Take on an empty stomach
* Encourage compliance |
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Isoniazid - Pharmacokinetics
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* PO, IM; dose 5 mg/kg (300 mg): Pedi 10 mg/kg (300 mg)
* Hepatically metabolized * Excreted by the kidneys |
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Isoniazid - Adverse Effects
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1) Depletes Pyridoxine (B6) causing peripheral neuropathy. So give B6 in conjunction with isoniazid
2) Hepatoxicity- monitor AST and ALT q month (jaundice) 3) Burning dark urine, jaundice, tingling |
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Isoniazid Drug Interactions
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* ETOH > INH metabolism which > risk of hepatoxicity
* Antacids < INH absorption * Disulfiram (Antabuse) so do not drink alcohol while taking Isoniazid |
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Rifampin MOA
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* Broad spectrum antibiotic against tb and N. meningitis
* Bacterialcidal blocks RNA transcription |
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Rifampin Pharmacokinetics
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* PO 600 mg/d; Pedi serum 10-20 mg/kg/day
* Peak serum 1.5 – 4 h * Half-life – 5 h * Hepatically metabolized * Excreted in feces |
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Rifampin Adverse Effects
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* Anorexia, discoloration of body fluids
* Pruritus, rash, mouth/tongue soreness * Chills, respiratory difficulty, shivers, fever, H/A, b0ne/muscle pain |
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Rifampin Drug Interactions
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* ETOH > hepatotoxicity risk
* < Corticosteroids effectiveness * HIV protease inhibitors * INH > hepatotoxicity risk. |
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Rifampin Nursing Management
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* Baseline and periodic hepatic function
* Give with 240 ml water on empty stomach * Given concurrently with other antitubercular drugs x 6 mo- 2yr * Alert client of reddish-brown discoloration of body fluids * Alternate form of contraception * Avoid ETOH |
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Pyrazinamide Pharmacokinetics
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* dose: 5-8.75 mg/kg q 6 h (max 3 g/d): Pedi 5.t-15 mg/kg bid (max 1.5 g)
* Peak serum 1-2 h * Half-life – 9-10 h * Hepatically metabolized * Excreted by kidneys |
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Pyrazinamide Adverse Effects
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Urination difficulties, Pruritus, rash, photosensitivity, jaundice, joint pain and swelling.
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Ethambutol MOA
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* Bacteriostatic suppresses RNA synthesis
* Effective ONLY against actively dividing mycobacterium |
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Ethambutol Pharmacokinetics
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dose: PO 15 mg/kg/day
* Take with food * Do not use in children < 13 y/o * Peak serum 2-4 hours * Half-life – 3-4 hours * Heapatically metabolized * Excreted by kidney |
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Ethambutol Adverse Effects
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* Caution: Optic neuritis and renal impairment
* Optic neuritis – blurred vision, loss of red-green perception * Chills, joint pain/swelling |
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Streptomycin (Aminoglycoside) Pharmacokinetics
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15 mg/kg/day or up to 1 g biw-tiw pedi 20 mg/kg/day
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Streptomycin Adverse Effects
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* Tinnitus
* Nephrotoxicity * Hepatotoxicity |
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Tuberculosis Management
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* Give INH, ethambutol, rifampin single OBSERVED dose qd
* Give rifampin 1 h before or 2 h after meal * Streptomycin deep IM, rotate sites * Report severe GI problems, yellow sclera, dark urine, clay-colored stool, vision, hearing changes, numbness or tingling |
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Expectorants (Guaifenesin) MOA
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* Irritates the gastric mucosa and stimulates respiratory tract secretions.
* Take with a lot of water * Sugar and alcohol content |
