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82 Cards in this Set

  • Front
  • Back
What is the definition of asthma?
• chronic inflammatory disorder of the airways in which many cells and cellular elements play a role

• recurrent episodes of breathlessness, chest tightness, cough, & wheezing

• episodes usually are reversible either spontaneously or with treatment

• inflammation causes an increase in bronchial hyperesponsiveness to a variety of stimuli
Describe the pathogenesis of asthma
• initial trigger activates inflammatory mediators from mast cells, alveolar macropohages, & epithelial cells

• there is migration/activation of inflammtory infiltrate

• epithelial injury increases airway smooth muscle responsiveness causing airway obstruction
What inflammatory events can initiate airway obstruction?
• edema
• hypertrophy of the bronchioles
• mucous production
• smooth muscle contraction
What is the hallmark of asthma?
hyperreactivity of airways to physical, chemical, and pharmacologic stimuli
What are triggers of allergic asthma?
• changes in environment
• dander
• dust
• pollens
• respiratory infections
Name and describe the 2 phases of asthma exacerbation.
• Early phase: bronchoconstriction, mucous hypersecretion, & epithelial damage; reverses in 1-2 hrs; treated with ß2 agonists

• Late phase: begins 4 hrs after initial trigger, may last up to 24 hrs; prevented by inhaled corticosteroids
How much does the FEV decrease in exercise-induced asthma?
15-20% decrease in FEV
What is nocturnal asthma and what is its MOA?
• Worsening of asthma during sleep
• MOA: associated with a diurnal pattern of endogenous cortisol secretion and circulating epinephrine
What are signs and symptoms of asthma?
• chest tightness
• coughing
• dyspnea
• wheezing
What are the different classifications of asthma based on severity?
• mild intermittent: symptoms occuring less than once a week, nocturnal symptoms occuring less than twice a month

• mild persistent: symptoms occuring more than once a week, but less than once a day

• moderate persistent: daily symptoms

• severe persistent: continuous symptoms, frequent exacerbations and nocturnal asthma symptoms
What are the goals of asthma therapy?
• maintain normal pulmonary function
• maintain normal activity level
• revent recurrent exacerbations
• prevent chronic and troublesome symptoms
• provide optimal pharmacotherapy
What are the DOC for acute exacerbations and for exercised-induced asthma?
beta-2 agonist (bronchodilators)
What is the MOA of beta-2 agonists?
• relaxes airway smooth muscle by increasing cyclic AMP
• enhances mucociliary clearance
• decreases vascular permeability
What are side-effects of beta-2 agonists?
• hypokalemia
• hypomagnesemia
• insomnia
• nervousness
• tachycardia
• tremors
List 2 examples of bronchodilators (beta-2 agonists)
• Albuterol
• Levalbuterol (Xopenex): has less incidence of tachycardia
What is the dosing for albuerol or levalbuterol?
2 puffs Q4-Q6 PRN
What is the DOC of nocturnal asthma?
Salmeterol (Serevent)
Name a long-acting beta-2 agonist
Salmeterol (Serevent)
What is the dosing of Salmeterol (Serevent) for exercised-induced asthma and prophylaxis?
• 2 puffs 30-60 minutes prior to exercise
• Prophylaxis: 2 puffs Q12 (not recommended)
Give examples of Methylxanthines
• Theophylline
• Amiophylline (IV form)
What is the MOA of Theophylline?
• smooth muscle relaxation from phosphodiesterase inhibitition & possibly adenosine antagonism
• increases diaphargm contractility & mucociliary clearance
What are indications for using Theophylline?
• long term control
• prevention of symptoms
What are side effects of Theophylline?
• with usual doses:
- GI upset
- insomnia

• with increased levels:
- arrhythmia
- headache
- nausea/vomiting
- seizures
- tachycardia
What is the usual dose for Theophylline?
100-300 mg PO BID
What is the effect of smoking on Theophylline?
smoking increases the clearance of Theophylline
What is the serum therapeutic range for Theophylline?
5-15 mcg/ml
What is the effect of Theophylline on Warfarin?
• Theophylline will decrease INR levels
• become more prone to clots
• will have to increase Warfarin dose
What are drugs that increase Theophylline levels?
• Antifungals
• Erythromycin (also binds drugs)
• Tagamet
What drugs will decrease Theophylline levels?
Name an anticholinergic used to treat asthma
Ipratropium (Atrovent)
What is the MOA of Ipratropium (Atrovent)?
• competitive inhibition of muscarin cholinergic receptors
• reduces intrinsic vagal tone to airway
When do you use Ipratropium (Atrovent)?
• if beta-2 agonists are contraindicated
• for additive benefit to inhale beta-2 agonists
What are side effects of Ipratropium (Atrovent)?
• blurred vision
• cough
• dry mouth
• flushed skin
• headache
• palpitations
• tachycardia
What are available formulations of Ipratropium (Atrovent)?
• metered-dose inhaler (MDI)
• nebulizer
A patient with this allergy can not be given Ipratropium (Atrovent)
What is the DOC for asthma prophylaxis?
inhaled corticosteroids
What is the MOA of inhaled corticosteroids in asthma therapy?
blocks late reaction
What are side effects of inhaled corticosteroids?
• dry mouth
• growth suppression in children
• hoarseness
• pharyngitis
• thrush
List examples of inhaled corticosteroids
• Beclomethasone (Beclovent, Vanceril)
• Budesonide (Pulmicort)
• Flunisolide (Aerobid)
• Fluticasone (Flovent)
• Triamcinolone (Azmacort)
Which is the only inhaled corticosteroid that can be mixed with a nebulizer?
Budesonide (Pulmicort)
Give 2 examples of mast cell stabilizers
• Cromolyn Sodium (Intal)
• Nedocromil Sodium (Tilade)
What is the MOA of Cromolyn Sodium (Intal)?
• mast cell stablizer
• blocks early and late reaction
What are indications for use of Cromolyn Sodium (Intal)?
• prophylaxis of asthma
• prevention of exercised-induced asthma
What are side effects of Cromolyn Sodium (Intal)?
• bad taste
• cough
• throat irriation
• wheezing
What is the dose of Cromolyn Sodium (Intal) for exercised-induced asthma?
2 puffs prior to exercise
Which asthma therapy is the DOC for children?
Cromolyn Sodium (Intal)
What is the MOA of Nedocromil Sodium (Tilade)?
inhibits activation and mediator release from:
• eosinophils
• leukotrienes
• macrophages
• mast cells
• monocytes
• neutrophils
What are indications of Nedocromil Sodium (Tilade)?
mild to moderate asthma
What are side effects of Nedocromil Sodium (Tilade)?
• cough
• unpleasant taste
What is the dose for Nedocromil Sodium (Tilade)?
2 puffs QID
What are indications to using leukotriene inhibitors?
considered alternatives to low dose of inhaled corticosteroids or cromolyn in mild persistent asthma
List examples of leukotriene inhibitors
• Montelukast (Singular)
• Zafirlukast (Accolate)
• Zileuton (Zyflo)
What is the MOA of Zafirlukast (Accolate), Zileuton (Zyflo), and Monteleukast (Singulair)?
• Singular and Accolate are leukotriene receptor antagonists
• Zyflo inhibits 5-lipoxygenase activity
What is the dosing, adverse effects, & drug interactions of Zafirleukast (Accolate)?
• Dose: 20 mg PO BID
• ADE: headache, GI
• DI: Warfarin, Erythromycin, Theophylline
Which leukotriene inhibitor can cause hepatotoxicity and increase LFTs?
Zileuton (Zyflo)
What is the dosing and adverse effects of Monteleukast (Singulair)?
• Dose: 10 mg PO QD
• ADE: headache, GI
What do peak flow meters measure?
peak expiratory flow rate (PEFR)
Describe the 3 levels of peak expiratory flow rate
• green zone: 80-100%
• yellow zone: 50-80%
• red zone: less than 50% (medical alert)
What is the function of spacers?
• allows evaporation of propellant prior to inhalation
• easier to take puffs in
Name 2 drugs that can induce asthma
• Aspirin/NSAIDS (5-20% of asthmatics are aspirin sensitive)
• Beta-blockers (use selective beta-blockers if necessary)
What is the treatment for mild intermittent asthma?
• Long-term control: no daily meds needed
• Quick-relief: inhaled beta-2 agonist
What is the treatment for mild persistent asthma?
• Long-term control:
- low dose inhaled corticosteroid (preferred)
- cromolyn/nedocromil, leukotriene modifier, or Theophylline SR

• Quick relief: inhaled beta-2 agonist
What is the treatment for moderate persistent asthma?
• Long-term control:
- preferred: inhaled steroid (low-medium dose) + long-acting beta-2 agonists (ADVAIR)
- alternative: inhaled steroid (medium dose) OR inhaled steroid (low-medium dose) + (leukotriene inhibitor OR Theophylline SR)

• Quick Relief: inhaled beta-2 agonist
What is the treatment for severe persistent asthma?
• Long-term control: inhaled steroid (high dose) + long-acting beta-2 agonist (Salmeterol); can add corticosteroid tablet or syrup if needed

• Quick relief: inhaled beta-2 agonist
Name a monoclonal antibody that can be used to treat asthma
Omalizumab (Xolair)
What are indications for Omalizumab (Xolair)?
for severe asthma attacks triggered by an allergy
What is the MOA of Omalizumab (Xolair)?
inhibits IgE binding to high-affinity IgE receptors on mast cells and basophils
What are side effects of Omalizumab (Xolair)?
• anaphylaxis
• injection site reactions
• malignancy
• thrombocytopenia
• urticaria
What are characterisitcs of chronic bronchitis?
• excess mucous production resulting in airway obstruction due ot inflammation and edema of the bronchiole
• occurs at least 3 months of the year for at least 2 years
What is emphysema?
• abnormal, permanent enlargement of the air spaces distal to the terminal bronchiole
• reduces surface area for the exchange of oxygen and carbon dioxide
What are risk factors for COPD?
• Major:
- smoking (#1)
- alpha-1 antitrypsin deficiency
- age
- males
- occupation

• Minor:
- air
- alcohol
- family history
- race
What is the pathophysiology of chronic bronchitis?
• bronchial irritation and inflammation causing mucous production
• hypoxemia causing erythropoesis leading to polycythemia
• infection
What is the goals of therapy for patients with COPD?
• improvement of chronic obstructive state
• prevention of acute exacerbations
• reduction of rate disease progression
• reduction in morbidity and mortality
• smoking cessation
What is the DOC for COPD and what is its MOA?
Ipratropium (Atrovent) causing brochodilation by competively inhibiting cholinergic receptors in bronchial smooth muscle
What drug should be used to treat acute COPD exacerbation?
• beta-2 agonists in combination with Ipratropium
• Combivent (Albuterol + Ipratropium)
What drug can be used for long-term treatment of COPD?
10% of patients respond to oral anti-inflammatory agents. What is the MOA of action of these agents in treating COPD?
• decrease capillary permeability to decrease mucous
• inhibits prostaglandins
What is the benefit and goal of long-term oxygen therapy in treating COPD?
• Benefit: decreased mortality
• Goal: PaO2 greater than 60 mm Hg
What are indications for home use of oxygen?
• severe resting arterial hypoxemia (PaO2 < 55)
• less severe hypoxemia (PaO2 55-59) with evidence of tissue hypoxemia
Which COPD patients are candidates for antibiotic therapy?
patients with symptoms of bronchial infections (such as purulent sputum)
What are some organisms that can cause bronchial infection in COPD patients?
• S. pneumoniae
• H. Flu
What is the DOC for COPD patients requiring antibiotic therapy?
• Amoxicillin is DOC
• Bactrim (if PCN allergic)