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82 Cards in this Set
- Front
- Back
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What is the definition of asthma?
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• 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 |
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Describe the pathogenesis of asthma
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• 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 |
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What inflammatory events can initiate airway obstruction?
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• edema
• hypertrophy of the bronchioles • mucous production • smooth muscle contraction |
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What is the hallmark of asthma?
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hyperreactivity of airways to physical, chemical, and pharmacologic stimuli
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What are triggers of allergic asthma?
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• changes in environment
• dander • dust • pollens • respiratory infections |
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Name and describe the 2 phases of asthma exacerbation.
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• 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 |
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How much does the FEV decrease in exercise-induced asthma?
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15-20% decrease in FEV
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What is nocturnal asthma and what is its MOA?
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• Worsening of asthma during sleep
• MOA: associated with a diurnal pattern of endogenous cortisol secretion and circulating epinephrine |
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What are signs and symptoms of asthma?
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• chest tightness
• coughing • dyspnea • wheezing |
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What are the different classifications of asthma based on severity?
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• 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 |
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What are the goals of asthma therapy?
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• maintain normal pulmonary function
• maintain normal activity level • revent recurrent exacerbations • prevent chronic and troublesome symptoms • provide optimal pharmacotherapy |
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What are the DOC for acute exacerbations and for exercised-induced asthma?
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beta-2 agonist (bronchodilators)
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What is the MOA of beta-2 agonists?
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• relaxes airway smooth muscle by increasing cyclic AMP
• enhances mucociliary clearance • decreases vascular permeability |
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What are side-effects of beta-2 agonists?
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• hypokalemia
• hypomagnesemia • insomnia • nervousness • tachycardia • tremors |
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List 2 examples of bronchodilators (beta-2 agonists)
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• Albuterol
• Levalbuterol (Xopenex): has less incidence of tachycardia |
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What is the dosing for albuerol or levalbuterol?
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2 puffs Q4-Q6 PRN
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What is the DOC of nocturnal asthma?
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Salmeterol (Serevent)
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Name a long-acting beta-2 agonist
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Salmeterol (Serevent)
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What is the dosing of Salmeterol (Serevent) for exercised-induced asthma and prophylaxis?
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• 2 puffs 30-60 minutes prior to exercise
• Prophylaxis: 2 puffs Q12 (not recommended) |
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Give examples of Methylxanthines
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• Theophylline
• Amiophylline (IV form) |
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What is the MOA of Theophylline?
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• smooth muscle relaxation from phosphodiesterase inhibitition & possibly adenosine antagonism
• increases diaphargm contractility & mucociliary clearance |
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What are indications for using Theophylline?
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• long term control
• prevention of symptoms |
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What are side effects of Theophylline?
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• with usual doses:
- GI upset - insomnia • with increased levels: - arrhythmia - headache - nausea/vomiting - seizures - tachycardia |
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What is the usual dose for Theophylline?
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100-300 mg PO BID
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What is the effect of smoking on Theophylline?
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smoking increases the clearance of Theophylline
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What is the serum therapeutic range for Theophylline?
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5-15 mcg/ml
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What is the effect of Theophylline on Warfarin?
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• Theophylline will decrease INR levels
• become more prone to clots • will have to increase Warfarin dose |
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What are drugs that increase Theophylline levels?
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• Antifungals
• Erythromycin (also binds drugs) • Tagamet |
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What drugs will decrease Theophylline levels?
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Quinolones
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Name an anticholinergic used to treat asthma
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Ipratropium (Atrovent)
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What is the MOA of Ipratropium (Atrovent)?
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• competitive inhibition of muscarin cholinergic receptors
• reduces intrinsic vagal tone to airway |
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When do you use Ipratropium (Atrovent)?
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• if beta-2 agonists are contraindicated
• for additive benefit to inhale beta-2 agonists |
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What are side effects of Ipratropium (Atrovent)?
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• blurred vision
• cough • dry mouth • flushed skin • headache • palpitations • tachycardia |
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What are available formulations of Ipratropium (Atrovent)?
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• metered-dose inhaler (MDI)
• nebulizer |
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A patient with this allergy can not be given Ipratropium (Atrovent)
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peanuts
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What is the DOC for asthma prophylaxis?
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inhaled corticosteroids
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What is the MOA of inhaled corticosteroids in asthma therapy?
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blocks late reaction
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What are side effects of inhaled corticosteroids?
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• dry mouth
• growth suppression in children • hoarseness • pharyngitis • thrush |
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List examples of inhaled corticosteroids
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• Beclomethasone (Beclovent, Vanceril)
• Budesonide (Pulmicort) • Flunisolide (Aerobid) • Fluticasone (Flovent) • Triamcinolone (Azmacort) |
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Which is the only inhaled corticosteroid that can be mixed with a nebulizer?
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Budesonide (Pulmicort)
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Give 2 examples of mast cell stabilizers
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• Cromolyn Sodium (Intal)
• Nedocromil Sodium (Tilade) |
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What is the MOA of Cromolyn Sodium (Intal)?
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• mast cell stablizer
• blocks early and late reaction |
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What are indications for use of Cromolyn Sodium (Intal)?
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• prophylaxis of asthma
• prevention of exercised-induced asthma |
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What are side effects of Cromolyn Sodium (Intal)?
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• bad taste
• cough • throat irriation • wheezing |
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What is the dose of Cromolyn Sodium (Intal) for exercised-induced asthma?
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2 puffs prior to exercise
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Which asthma therapy is the DOC for children?
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Cromolyn Sodium (Intal)
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What is the MOA of Nedocromil Sodium (Tilade)?
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inhibits activation and mediator release from:
• eosinophils • leukotrienes • macrophages • mast cells • monocytes • neutrophils |
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What are indications of Nedocromil Sodium (Tilade)?
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mild to moderate asthma
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What are side effects of Nedocromil Sodium (Tilade)?
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• cough
• unpleasant taste |
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What is the dose for Nedocromil Sodium (Tilade)?
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2 puffs QID
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What are indications to using leukotriene inhibitors?
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considered alternatives to low dose of inhaled corticosteroids or cromolyn in mild persistent asthma
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List examples of leukotriene inhibitors
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• Montelukast (Singular)
• Zafirlukast (Accolate) • Zileuton (Zyflo) |
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What is the MOA of Zafirlukast (Accolate), Zileuton (Zyflo), and Monteleukast (Singulair)?
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• Singular and Accolate are leukotriene receptor antagonists
• Zyflo inhibits 5-lipoxygenase activity |
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What is the dosing, adverse effects, & drug interactions of Zafirleukast (Accolate)?
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• Dose: 20 mg PO BID
• ADE: headache, GI • DI: Warfarin, Erythromycin, Theophylline |
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Which leukotriene inhibitor can cause hepatotoxicity and increase LFTs?
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Zileuton (Zyflo)
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What is the dosing and adverse effects of Monteleukast (Singulair)?
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• Dose: 10 mg PO QD
• ADE: headache, GI |
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What do peak flow meters measure?
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peak expiratory flow rate (PEFR)
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Describe the 3 levels of peak expiratory flow rate
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• green zone: 80-100%
• yellow zone: 50-80% • red zone: less than 50% (medical alert) |
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What is the function of spacers?
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• allows evaporation of propellant prior to inhalation
• easier to take puffs in |
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Name 2 drugs that can induce asthma
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• Aspirin/NSAIDS (5-20% of asthmatics are aspirin sensitive)
• Beta-blockers (use selective beta-blockers if necessary) |
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What is the treatment for mild intermittent asthma?
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• Long-term control: no daily meds needed
• Quick-relief: inhaled beta-2 agonist |
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What is the treatment for mild persistent asthma?
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• Long-term control:
- low dose inhaled corticosteroid (preferred) - cromolyn/nedocromil, leukotriene modifier, or Theophylline SR • Quick relief: inhaled beta-2 agonist |
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What is the treatment for moderate persistent asthma?
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• 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 |
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What is the treatment for severe persistent asthma?
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• 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 |
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Name a monoclonal antibody that can be used to treat asthma
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Omalizumab (Xolair)
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What are indications for Omalizumab (Xolair)?
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for severe asthma attacks triggered by an allergy
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What is the MOA of Omalizumab (Xolair)?
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inhibits IgE binding to high-affinity IgE receptors on mast cells and basophils
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What are side effects of Omalizumab (Xolair)?
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• anaphylaxis
• injection site reactions • malignancy • thrombocytopenia • urticaria |
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What are characterisitcs of chronic bronchitis?
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• 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 |
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What is emphysema?
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• abnormal, permanent enlargement of the air spaces distal to the terminal bronchiole
• reduces surface area for the exchange of oxygen and carbon dioxide |
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What are risk factors for COPD?
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• Major:
- smoking (#1) - alpha-1 antitrypsin deficiency - age - males - occupation • Minor: - air - alcohol - family history - race |
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What is the pathophysiology of chronic bronchitis?
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• bronchial irritation and inflammation causing mucous production
• hypoxemia causing erythropoesis leading to polycythemia • infection |
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What is the goals of therapy for patients with COPD?
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• improvement of chronic obstructive state
• prevention of acute exacerbations • reduction of rate disease progression • reduction in morbidity and mortality • smoking cessation |
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What is the DOC for COPD and what is its MOA?
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Ipratropium (Atrovent) causing brochodilation by competively inhibiting cholinergic receptors in bronchial smooth muscle
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What drug should be used to treat acute COPD exacerbation?
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• beta-2 agonists in combination with Ipratropium
• Combivent (Albuterol + Ipratropium) |
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What drug can be used for long-term treatment of COPD?
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Salmeterol
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10% of patients respond to oral anti-inflammatory agents. What is the MOA of action of these agents in treating COPD?
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• decrease capillary permeability to decrease mucous
• inhibits prostaglandins |
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What is the benefit and goal of long-term oxygen therapy in treating COPD?
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• Benefit: decreased mortality
• Goal: PaO2 greater than 60 mm Hg |
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What are indications for home use of oxygen?
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• severe resting arterial hypoxemia (PaO2 < 55)
• less severe hypoxemia (PaO2 55-59) with evidence of tissue hypoxemia |
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Which COPD patients are candidates for antibiotic therapy?
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patients with symptoms of bronchial infections (such as purulent sputum)
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What are some organisms that can cause bronchial infection in COPD patients?
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• S. pneumoniae
• H. Flu |
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What is the DOC for COPD patients requiring antibiotic therapy?
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• Amoxicillin is DOC
• Bactrim (if PCN allergic) |
