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What is the relevance of asthma?
- Affects an estimated 17.5 to 20.5 million people (7.7%) in the U.S. alone
- ~450,000 hospitalizations per year
- ~1.8 million Emergency Room visits per year
- 1.1 deaths per 100,000 per year
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What is the definition of asthma?
- Chronic inflammatory disorder characterized by variable and recurring symptoms, airflow obstruction and bronchial hyper-responsiveness.
- Frequency and severity of symptoms depends on the individual.
- Some symptoms, such as hyper-production of mucous, cause other symptoms (e.g. non-productive cough).
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What are the symptoms of asthma?
- wheezing
- shortness of breath
- chest tightness
- cough (worse at night)
- hyper-production of mucous
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What are possible triggers of asthma?
- pollen
- smoke
- dust mites
- pets
- mold
- weather
- exercise
- food
- colds/infections
- bugs (e.g. cockroach feces)
- toys/stuffed animals
- house plants
- cooking (e.g. fumes, heat, smells)
- flames
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What is the relevance of Chronic Obstructive Pulmonary Disease (COPD)?
- Fourth leading cause of chronic morbidity & mortality in the U.S.
- 34.2 deaths per 100,000 population per year
- As far as statistics go, COPD is a bigger deal than asthma
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What is the definition of COPD?
- Chronic Obstructive Pulmonary Disease (COPD)
- Used to be called emphysema or chronic bronchitis, but now these are lumped together as COPD
- Progressive airflow limitation (not fully reversible) associated with abnormal inflammation and lung damage
- gets worse with time
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What are the symptoms of COPD?
- shortness of breath
- *chronic cough
- *chronic sputum production
- *hallmark symptoms
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What are the causes of COPD?
- tobacco (main cause)
- occupational toxins/hazards (e.g. coal miner)
- indoor/outdoor pollution
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Asthma Treatment
- Avoid triggers
- Peak flow meter readings
- Asthma Action Plan
- Manage symptoms:
- -fast-acting (rescue) inhaler for all patients
- -other medications based on stage of disease (e.g. "step-up therapy")
- -cornerstone of therapy = inhaled corticosteroids
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COPD Treatment
- Risk reduction
- -smoking cessation
- -prevent progression
- Managing stable disease:
- -short-acting inhaler for symptom management
- -other medications based on stage of disease (e.g "step-up therapy")
- -cornerstone therapy = long-acting bronchodilator
Manage Exacerbations
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What is the cornerstone therapy for asthma?
inhaled corticosteroids
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What is the cornerstone therapy for COPD?
long-acting bronchodilator
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What are the two main drug classes of bronchodilators?
- Beta agonists:
- -albuterol
- -stimulation of beta-2 adrenergic receptor sites
- -bronchial smooth muscle relaxation
- -stimulates skeletal muscle resulting in tremor
- Anticholinergics:
- -ipratropium
- -blocks acetylcholine
- -results in airway dilation
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Other Medications
- Corticosteroids:
- -fluticasone
- -decrease inflammation
- -an immunosuppressant
- -inhaled = staple of therapy for persistent asthma, but must rinse mouth after use to prevent thrush
- -oral = for severe asthma or for exacerbations
- Leukotriene modifiers:
- -singulair
- -blocks body's production of leukotriene, which normally act as signaling molecules to cause contraction in the trachea
- -decreases inflammation to keep airways open
- -not recommended or indicated in COPD
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Which pharmacological treatment may cause skeletal muscle tremors?
- beta-2 adrenergic agonistsexample would be albuterol
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Which pharmacological treatment blocks acetylcholine, which is associated with cholinergic PNS transmission?
- anticholinergics
- example would be ipratropium
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Which pharmacological treatment is the staple of therapy for persistent asthma?
- inhaled corticosteroids
- example would be fluticasone
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Which pharmacological treatment must one rinse their mouth after using and why?
- inhaled corticosteroids
- may cause thrush if medication not rinsed from mouth
- example would be fluticasone
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Which pharmacological treatment is not recommended or indicated for COPD?
- leukotriene modifiers
- example would be singulair
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Asthma & COPD Drug List
- Key:
- SABA = short-acting beta agonist
- LABA = long-acting beta agonist
- SAA = short-acting anticholinergic
- LAA = long-acting anticholinergic
- ICS = inhaled corticosteroid
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Asthma & COPD Combination Drug List
- Key:
- SABA = short-acting beta agonist
- LABA = long-acting beta agonist
- SAA = short-acting anticholinergic
- LAA = long-acting anticholinergic
- ICS = inhaled corticosteroid
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What is a Peak Flow Meter?
A device that measures control of asthma
- How to use:
- -use standing
- -breathe into device quickly
- -similar to blowing out birthday candles from across the room
- -should record personal best when feeling well
- -take multiple measurements to ensure accuracy
- The device results dictate different zone areas:
- -red (< 50% of personal best)
- -yellow (> 50-80% of personal best)
- -green (80-100% of personal best)
- Readings vary according to:
- -age
- -gender
- -height
- -every score is individualized to the person
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What is an Asthma Action Plan?
Uses symptoms and/or peak flow meter readings to guide patient on proper therapy and provide steps to treat asthma.
Goal is to decrease incidence of attack and decrease # of emergency room visits.
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What is the difference in administration between inhalers?
- Metered dose: uses chemical propellants to expel the medication from the inhaler device. Often called "puffers."
- Dry powder: release the medication via rapid inhalation instead of using chemical propellants. Often called "diskus."
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What is a spacer?
- Using a spacer with a metered dose inhaler (MDI) has the following benefits:
- -the technique of using an MDI is easier
- -more of the drug gets into the lungs
- -there are less unpleasant side effects
- -more comfortable for the patient
- -useful for children
- However, keep in mind:
- -often times you need a prescription for a spacer
- -many times insurance won't cover them
- -beneficial for metered dose inhalers only
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What is a nebulizer and how is it used?
- uses a face mask or mouthpiece to deliver medication in the form of a fine mist (aerosol)
- breathe in the nebulized medication through the mouthpiece or face mask
- very common to use with children
- more time consuming...must breathe in until mist is gone, which usually takes 5 to 15 minutes
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Counseling points on Metered Dose Inhalers (MDIs)
- Remove cap and shake well
- Shake at least 10x
- Breathe out and then place mouthpiece into mouth
- Push canister down into case
- Take a slow, deep breath in
- When lungs are completely full, hold breath for 10 seconds
- If second puff needed, wait at least one minute between puffs
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Counseling points on Nebulizers
- open medication and place in cup
- fasten mouthpiece or mask to cup and attach the tubing of the compressor
- put lips around mouthpiece
- turn on nebulizer so that liquid medication vaporized
- take slow, deep breaths through mouth while holding each breath one to two seconds
- continue until mist is gone (~10 minutes)
- If using a corticosteroid in conjunction with another medication, use the corticosteroid first so that the maximum amount of medication gets in through dilated airways
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Counseling points on Dry Powder DISK Inhalers
- Slide lever open only once
- Put lips around mouthpiece and breathe in steadily and deeply
- Take a full breath and hold for 10 seconds
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Counseling points on Dry Powder HANDIHALER (Spiriva)
- Open dust cap
- Open mouth piece
- Place capsule into center chamber and close mouthpiece (should hear click)
- Press side button to pierce capsule
- Breathe out completely (not into mouthpiece)
- Place lips around mouthpiece (don't block vents)
- Breathe in slowly and deeply (should hear capsule rattle) until lungs are full
- Hold for as long as comfortable (~10 seconds)
- Unique because you must pierce the powder medication for each dose
- Clean device mouthpiece only with water, but be careful not to get water inside inhaler
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What dosage forms are available for albuterol?
- nebulizer solution
- oral solution
- tablet
- extended-release tablet
- aerosol solution
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What dosage forms are other medications in?
- levalbuterol: nebulizer, aerosol
- ipratropium: nebulizer, aerosol
- tiotropium: capsule pierced for aerosol
- fluticasone: aerosol, nasal spray, ointment, cream
- triamcinolone: tablet, aerosol, injection
- budesonide: aerosol, powder, capsule, oral suspension
- montelukast: tablet, chewable tablet, oral packet
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