-
3 quick relief medications for asthma
- short-acting beta 2 agonists (SABAs)
- systemic corticosteroids
- anticholinergics
-
3 adverse effects of ICS's
- oropharyngeal candidiasis
- hoarsness, other voice changes
- reflex cough
-
2 pertinent counseling points for ICS
- not to be used for acute symptoms or as needed
- rinse and spit
-
list inhaled corticosteroids
- beclomethasone
- budesonide
- flunisolide
- fluticasone
- ciclesonide
- mometasone
- triamcinolone
-
what population would an ICS be good for
those with persistent asthma secondary to airway remodeling by preventing irreversible loss of lung function
-
How do ICS's work, 5 mechanisms
- most potent, effective anti-inflammatory
- reduce mucus production and hypersecretion
- increase # of beta 2 receptors
- improve beta 2 responsiveness
- blocks late phase response to allergens and reduces airway responsiveness
-
pertinent counseling points for LABA 4 points
- not to be used for acute symptoms or as needed
- not to be used for acute symptoms or exacerbations
- should never be used for monotherapy in asthma
-
LABA adverse effects
- tachycardia
- "jitteriness"
- tremor
-
how do LABA's work 2 mechanisms
- functional bronchodilators
- modest anti-inflammatory effects
-
what is the effect of LABA tolerance
down regulation after about a week of chronic use which will have the same peak effect just a shorter duration
-
-
ICS and LABA combo products
- advair diskus
- advair HFA
- symbicort
-
LTRA adverse effects
potential for neuropsychiatric symptoms
-
leukotriene receptor antagonists
-
5-lipoxygenase inhibitor
zileuton
-
how do LTRA's work
reduce airway hyperresponsiveness to a brad rang of stimuli - allergens, exercise, cold air, irritants, aspirin
-
what general pt population would LRTA be used in
- mild persistent asthma - long term control and prevention of symptoms
- moderate persistent asthma - in combo w/ ICS
-
what 3 specific pt population groups would LRTA be useful for
- smokers
- ICS - resistant asthma
- children with allergies
-
mast cell stabilizers
- cromolyn sodium
- nedocromil sodium
-
pt population in which you would use mast cell stabilizers
- prophylaxis of mild persistent asthma
- preventative Tx for EIB or know allergies
has fallen out of favor due to ICS use and not a lot of data on effectiveness. May be used if a parent is totally against inhaler therapy
-
immunomodulator
omalizumab
-
how do immunomodulators work
recombinant human monoclonal antibody which binds to Fc portion of IgE
-
pt population who would benefit from an immunomodulator
- moderate - severe persistent asthma inadequately controlled with ICS in pt > 12 yo with documented aeroallergies
- step 4 of therapy chart
-
pertinent counseling points for immunomodulators 4
- Sub Q q 2-4 weeks
- dosing based on weight and IgE levels
- boxed warning for anaphylaxis - could be 2 hours delayed
- increased risk of cardiovascular and cerebrovascular events
-
methylxanthine
theophylline
-
how do methylxanthines work
- moderate bronchodilator with minor anti-inflammatory activity
- increases mucociliary clearance and diaphragm contractility
-
SABA's
- albuterol
- levalbuterol
- pirbuterol
-
SABA adverse effects
- tachycardia
- "jitteriness"
- tremor
-
how do SABA's work
most effective bronchodilators
-
when should SABA's be used
- first line for all pts with asthma as quick relief medication
- acute asthma symptoms
- exacerbations
- prevention of exercise induced bronchospasm
-
counseling points for SABA's
- should not be used as daily control medication
- if used greater than 2 days per week, signifies inadequate asthma control and should be reviewed by physician
-
systemic corticosteroids
- prednisone
- prednisolone
- methylprednisolone
-
counseling points for systemic corticosteroids
- take with food
- ensure pt understands tapering instructions
- if less than 10-14 days, don't need to taper off
- continue full dose until peak expiratory flow reaches 80% of predicted normal
-
how do systemic corticosteroids work
anti-inflammatory - and this helps to reduce beta 2 receptor downregulation from SABA's and improves sensitivity
-
what pt population would a systemic corticosteroid be used
moderate to severe exacerbations - "burst" to gain control, speed recovery and prevent relapse
-
-
how do anticholinergics work in asthma
bronchodilation for relief of acute bronchospasm where bronchoconstriction is cholinergically mediated
-
step 1 of asthma management
SABA prn
-
step 2 of asthma management
- SABA prn
- low dose ICS
- alternative
- cromolyn, nedocromil,LRTA or theophylline
-
step 3 of asthma management
- low dose ICA + LABA
- or
- medium dose ICS
- alternative
- low dose ICS + either LTRA, theophylline or
- zileuton
-
step 4 of asthma management
- medium dose ICS + LABA
- alternative
- medium dose ICS + either LTRA,theophylline
- or zileuton
-
step 5 of asthma management
- high dose ICS + LABA
- and
- consider omalizumab if allergies are comorbid condition
-
step 6 of asthma management
- high dose ICS + LABA + oral corticosteroid
- AND
- consider omalizumab if allergies are comorbid condition
-
7 risk factors for COPD
- genes - alpha 1 antitrypsin deficiency
- gender - male
- age - > 40
- history of respiratory infections
- existing lung dysfunction
- socioeconomic status
- inhalation exposure
- tobacco smoke
- occupational dusts and chemicals
- indoor & outdoor air pollution
-
4 airway areas that are affected by COPD
Small vasculature and parenchyma
- proximal airways
- peripheral airways
- lung parenchyma
- pulmonary vasculature
-
how do you differentiate between asthma and COPD with air exchange
- COPD - problem getting air out
- asthma - problem getting air in
-
how do you differentiate between COPD and asthma in terms of cough
- COPD - productive
- asthma - dry hacking
-
4 components of COPD management
- assess and monitor disease
- reduce risk factors
- manage stable COPD
- manage exacerbations
-
what 4 characteristics would make you consider COPD in an individual over age 40
- dyspnea
- chronic cough
- chronic sputum production
- history of exposure to risk factors
-
what 6 findings on a physical exam could support the diagnosis of COPD
- cyanosis
- pursed lip breathing
- presence of wheezing
- "barrel shaped" chest
- tachypnea
- lower extremity edema
-
COPD group A primary treatment
- SA anticholinergic prn
- or
- SA beta2 agonist prn
-
COPD group A secondary treatment
- LA anticholinergic
- or
- LA beta2 agonist
- or
- SA beta2 agonist and SA anticholinergic
-
COPD group A other possible treatments
theophylline
-
COPD group B primary treatment
- LA anticholinergic
- or
- LA beta2 agonist
-
COPD group B secondary treatment
- LA anticholinergic
- AND
- LA beta2 agonist
-
COPD group B alternative treatment
- SA beta2 agonist
- and/or
- SA anticholinergic
theophylline
-
COPD group C primary treatment
- ICS + LA beta2 agonist
- or
- LA anticholinergic
-
COPD group C secondary treatment
- LA anticholinergic and LA beta2 agonist
- or
- LA anticholinergic and PDE-4 inhibitor
- or
- LA beta2 agonist and PDE-4 inhibitor
-
COPD group C alternative treatment
- SA beta2 agonist
- and/or
- SA anticholinergic
theophylline
-
COPD group D primary treatment
- ICS + LA beta2 agonist
- and/or
- LA anticholinergic
-
COPD group D secondary treatment
- ICS + LA beta2 agonist and LA anticholinergic
- or
- ICS + LA beta2 agonist and PDE4 inhibitor
- or
- LA anticholinergic and LA beta2 agonist
- or
- LA anticholinergic and PDE4 inhibitor
-
COPD group D alternative treatment
carbocysteine
- SA beta2 agonist
- and/or
- SA anticholinergic
theophylline
-
8 indications for hospital assessment or admission from COPD
- marked increase in intensity of symptoms
- severe underlying COPD
- onset of new physical signs
- failure of an exacerbation to respond to initial medical management
- presence of serious comorbidities
- frequent exacerbations
- older age
- insufficient home support
-
Asthma Tx for step 1
SABA PRN
-
Asthma Tx for step 2 primary
preferred - low dose ICS
-
Asthma Tx for step 2 alternative
cromolyn, LTRA, nedocromil or theophylline
-
Asthma Tx for step 3 primary
- low dose ICS + LABA
- or
- medium-dose ICS
-
Asthma Tx for step 3 alternative
- low dose ICS + either LRTA
- theophylline
- zileuton
-
Asthma Tx step 4 primary
medium dose ICS + LABA
-
Asthma Tx for step 4 alternative
- medium dose ICS + either LRTA
- theophylline
- zileuton
-
Asthma Tx for step 5 primary
- high dose ICS + LABA
- and
- consider omalzumab for pts what have allergies
-
Asthma Tx for step 6
- High dose ICS + LABA + oral corticosteroid
- and
- consider omalizumab for pts who have allergies
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