thera asthma & COPD

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coal
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thera asthma & COPD
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2013-11-02 17:10:09
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thera asthma COPD
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thera asthma & COPD
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  1. 3 quick relief medications for asthma
    • short-acting beta 2 agonists (SABAs)
    • systemic corticosteroids
    • anticholinergics
  2. 3 adverse effects of ICS's
    • oropharyngeal candidiasis
    • hoarsness, other voice changes
    • reflex cough
  3. 2 pertinent counseling points for ICS
    • not to be used for acute symptoms or as needed
    • rinse and spit
  4. list inhaled corticosteroids
    • beclomethasone
    • budesonide
    • flunisolide
    • fluticasone
    • ciclesonide
    • mometasone
    • triamcinolone
  5. what population would an ICS be good for
    those with persistent asthma secondary to airway remodeling by preventing irreversible loss of lung function
  6. 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
  7. 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
  8. LABA adverse effects
    • tachycardia
    • "jitteriness"
    • tremor
  9. how do LABA's work 2 mechanisms
    • functional bronchodilators
    • modest anti-inflammatory effects
  10. 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
  11. LABA's
    • salmeterol
    • formoterol
  12. ICS and LABA combo products
    • advair diskus
    • advair HFA
    • symbicort
  13. LTRA adverse effects
    potential for neuropsychiatric symptoms
  14. leukotriene receptor antagonists
    • zafirlukast
    • montelukast
  15. 5-lipoxygenase inhibitor
    zileuton
  16. how do LTRA's work
    reduce airway hyperresponsiveness to a brad rang of stimuli - allergens, exercise, cold air, irritants, aspirin
  17. 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
  18. what 3 specific pt population groups would LRTA be useful for
    • smokers
    • ICS - resistant asthma
    • children with allergies
  19. mast cell stabilizers
    • cromolyn sodium
    • nedocromil sodium
  20. 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
  21. immunomodulator
    omalizumab
  22. how do immunomodulators work
    recombinant human monoclonal antibody which binds to Fc portion of IgE
  23. 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
  24. 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
  25. methylxanthine
    theophylline
  26. how do methylxanthines work
    • moderate bronchodilator with minor anti-inflammatory activity
    • increases mucociliary clearance and diaphragm contractility
  27. SABA's
    • albuterol
    • levalbuterol
    • pirbuterol
  28. SABA adverse effects
    • tachycardia
    • "jitteriness"
    • tremor
  29. how do SABA's work
    most effective bronchodilators
  30. 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
  31. 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
  32. systemic corticosteroids
    • prednisone
    • prednisolone
    • methylprednisolone
  33. 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
  34. how do systemic corticosteroids work
    anti-inflammatory - and this helps to reduce beta 2 receptor downregulation from SABA's and improves sensitivity
  35. what pt population would a systemic corticosteroid be used
    moderate to severe exacerbations - "burst" to gain control, speed recovery and prevent relapse
  36. anticholinergics
    • ipratropium
    • tiotropium
  37. how do anticholinergics work in asthma
    bronchodilation for relief of acute bronchospasm where bronchoconstriction is cholinergically mediated
  38. step 1 of asthma management
    SABA prn
  39. step 2 of asthma management
    • SABA prn
    • low dose ICS
    • alternative
    •   cromolyn, nedocromil,LRTA or theophylline
  40. step 3 of asthma management
    • low dose ICA + LABA
    •           or
    • medium dose ICS
    • alternative
    •   low dose ICS + either LTRA, theophylline or
    •   zileuton
  41. step 4 of asthma management
    • medium dose ICS + LABA
    • alternative
    •   medium dose ICS + either LTRA,theophylline
    •   or zileuton
  42. step 5 of asthma management
    • high dose ICS + LABA
    •          and
    • consider omalizumab if allergies are comorbid condition
  43. step 6 of asthma management
    • high dose ICS + LABA + oral corticosteroid
    •                     AND
    • consider omalizumab if allergies are comorbid condition
  44. 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
  45. 4 airway areas that are affected by COPD
    Small vasculature and parenchyma

    • proximal airways
    • peripheral airways
    • lung parenchyma
    • pulmonary vasculature
  46. how do you differentiate between asthma and COPD with air exchange
    • COPD - problem getting air out
    • asthma - problem getting air in
  47. how do you differentiate between COPD and asthma in terms of cough
    • COPD - productive
    • asthma - dry hacking
  48. 4 components of COPD management
    • assess and monitor disease
    • reduce risk factors
    • manage stable COPD
    • manage exacerbations
  49. 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
  50. 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
  51. COPD group A primary treatment
    • SA anticholinergic prn
    •             or
    • SA beta2 agonist prn
  52. COPD group A secondary treatment
    • LA anticholinergic
    •         or
    • LA beta2 agonist
    •       or
    • SA beta2 agonist and SA anticholinergic
  53. COPD group A other possible treatments
    theophylline
  54. COPD group B primary treatment
    • LA anticholinergic
    •          or
    • LA beta2 agonist
  55. COPD group B secondary treatment
    • LA anticholinergic
    •         AND
    • LA beta2 agonist
  56. COPD group B alternative treatment
    • SA beta2 agonist
    •      and/or
    • SA anticholinergic

    theophylline
  57. COPD group C primary treatment
    • ICS + LA beta2 agonist
    •          or
    • LA anticholinergic
  58. 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
  59. COPD group C alternative treatment
    • SA beta2 agonist
    •      and/or
    • SA anticholinergic


    theophylline
  60. COPD group D primary treatment
    • ICS + LA beta2 agonist
    •         and/or
    • LA anticholinergic
  61. 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
  62. COPD group D alternative treatment
    carbocysteine

    • SA beta2 agonist
    •        and/or
    • SA anticholinergic

    theophylline
  63. 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
  64. Asthma Tx for step 1
    SABA PRN
  65. Asthma Tx for step 2 primary
    preferred - low dose ICS
  66. Asthma Tx for step 2 alternative
    cromolyn, LTRA, nedocromil or theophylline
  67. Asthma Tx for step 3 primary
    • low dose ICS + LABA
    •           or
    • medium-dose ICS
  68. Asthma Tx for step 3 alternative
    • low dose ICS + either LRTA
    • theophylline
    • zileuton
  69. Asthma Tx step 4 primary
    medium dose ICS + LABA
  70. Asthma Tx for step 4 alternative
    • medium dose ICS + either LRTA
    • theophylline
    • zileuton
  71. Asthma Tx for step 5 primary
    • high dose ICS + LABA
    •         and
    • consider omalzumab for pts what have allergies
  72. Asthma Tx for step 6
    • High dose ICS + LABA + oral corticosteroid
    •                      and
    • consider omalizumab for pts who have allergies

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