Drug induced pulmonary disorders

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twinklemuse
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Drug induced pulmonary disorders
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2011-03-24 17:06:05
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Drug induced pulmonary disorders
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  1. vitamin E's chemical name. is it antioxidant or oxidant?
    • a-tocopherol
    • antioxidant
  2. oxidants are ___ _____, partially reduced oxygen metabolites.
    highly reactive
  3. mechanism of drug induced pulmonary disorder?
    • increased production of oxidant
    • inhibition of antioxidant system
    • so oxidant/antioxidant system is not balanced
  4. histology: is drug induced damage similar or different from idiopathic damage?
    similar
  5. what is the tissue separating respiratory blood flow from alveolar space?
    interstitium
  6. via what mechanism do O2 and CO2 pass btwn capillary?
    diffusion
  7. acute pulmonary edema symptoms. two categories? (II)
    • dyspnea, chest discomfort, tachypnea, hypoxemia, alveolar flooding
    • lead to acute respiratory distress syndrome (ARDS)
    • cardiogenic vs. non-cardiogenic
  8. cardiogenic acute pulmonary edema (II) symptoms. causal agents?
    • increased pressure, vague fatigue, mild pedal edema, exertional dyspnea
    • (left heart cannot pump well so fluid backed up in lungs)
    • caused by fluid overload and contrast media
  9. non-cardiogenic acute pulmonary edema (II). describe onset and pathophys. what agents cause?
    • immediate to days onset --> rapid alveolar flooding
    • caused by chemotherapy agents, naloxone, opiates
    • (alveolar damage, not heart)
  10. pulmonary hypertension (III).
    symptoms. pathophys. causal agents.
    • asymptomatic early then dyspnea, fatigue, chest pain. could be life threatening and chronic
    • burden on right ventricle . remodel and large size to compensate the pressure from lungs
    • stimulant appetite suppressant, maternal SSRI during pregnancy (high chance of pHTN with newborn)
  11. what is the most common drug induced lung disease?
    A) acute pulmonary edema
    B) pulmonary eosinophilia
    C) intersitital lung disease
    D) pulmonary htn
    C) intersitital lung disease
    (this multiple choice question has been scrambled)
  12. symptoms of interstitial lung disease (IV).
    • progressive dyspnea or non-productive cough
    • hemoptysis, wheeze, chest pain
    • interstitial opacities on CXR.
  13. progressive dyspnea or non-productive cough
    hemoptysis, wheeze, chest pain
    interstitial opacities on CXR.

    A) acute pulmonary edema
    B) pulmonary htn
    C) pulmonary eosinophilia
    D) interstitial lung disease
    D) interstitial lung disease
    (this multiple choice question has been scrambled)
  14. dyspnea, chest discomfort, tachypnea, hypoxemia, alveolar flooding.

    A) interstitial lung disease
    B) pulmonary eosinophilia
    C) acute pulmonary edema
    D) pulmonary htn
    C) acute pulmonary edema
    (this multiple choice question has been scrambled)
  15. asymptomatic, dyspnea, chest pain, fatigue.

    A) acute pulmonary edema
    B) pulmonary htn
    C) pulmonary eosinophilia
    D) interstitial lung disease
    B) pulmonary htn
    (this multiple choice question has been scrambled)
  16. three types of interstitial lung disease. (IV)
    • interstitial infiltrate/pneumonia
    • pulmonary fibrosis
    • bronchiolitis oliterans organzing pneumonia
  17. pulmonary fibrosis.

    A) pleural inflammation
    B) intersitital lung disease
    C) pulmonary eosinophilia
    D) drug hypersensitivity syndrome
    B) intersitital lung disease
    (this multiple choice question has been scrambled)
  18. bronchiolitis oliterans organizing pneumonia.

    A) pulmonary hytertension
    B) drug hypersensitivity syndrome
    C) interstitial lung disease
    D) pleural inflammation
    C) interstitial lung disease
    (this multiple choice question has been scrambled)
  19. what changes on CXR does interstitial infiltrate/pna (interstitial lung disease IV) have?
    fluid or cells btwn alveolus and capillary
  20. interstitial infiltrate/pna (interstitial lung disease IV) causal agents.
    • most common pulmonary tox of methotrexate
    • nitrofurantoin, epidermal growth factor receptor antagonist
  21. pathophys of pulmonary fibrosis (IV).
    • scarring of lung parenchyma and accumulation of excessive connective tissue
    • often secondary to a chronic inflamm process.
  22. causal agent of pulmonary fibrosis (IV).
    chemotherapy agent, amiodarone, ergot derivative, nitrofurantoin, illicit IV drug ("talc lung")
  23. pathophys of bronchiolitis obliterans organizing pnemonia (IV) (BOOP)
    inflamm of lung characterized by alveolar fibrosis
  24. causal agents of BOOP (IV).
    • antimicrobials
    • cyrotoxic drugs
    • "statins"
    • amiodraone
    • etc.
  25. pathophys of pulmonary eosinophilia (V). how is this confirmed?
    • eosinophils in alveolar space, interstitium or both.
    • confirmed by excessive eosinophils in biopsy or bronchoalveolar lavage
  26. how does pulmonary eosinophilia present in CXR? (V)
    typically ground glass opacities in peripheral and upper lobe distribution
  27. causal agents of pulmonary eosinophilia (V)
    • antimicrobial, NSAID, amiodarone, nitrofurantoin
    • (these were all part of hypersensitivity chart)
  28. pathophys of pleural inflamm and symptoms? (VI)
    • asymptomatic --> acute pleuritis --> pleural thickening
    • pleural effusion - chest pain, dyspnea, cough
  29. pleural effusion.

    A) diffuse alveolar hemorrhage
    B) pulmonary eosinophilia
    C) pleural inflammation
    D) diffuse alveolar damage
    C) pleural inflammation
    (this multiple choice question has been scrambled)
  30. causal agents of pleural inflammation (VI).
    • nitrofurantoin
    • ergot alkaloids
    • amiodarone
  31. pathophys of diffuse alveolar hemorrhage (VII).
    bleed from pulmonary capillaries --> RBC accumulate in alveolar space.
  32. symptoms of diffuse alveolar hemorrhage (VII)?
    hemoptysis, cough, progressive dyspnea --> intraalveolar clotting
  33. intra-alveolar clotting
    A) drug hypersensitivity syndrome
    B) pleural inflammation
    C) diffuse alveolar hemorrhage
    D) diffuse alveolar damage
    C) diffuse alveolar hemorrhage
    (this multiple choice question has been scrambled)
  34. causal agents of diffuse alveolar hemorrhage (VII)?
    • antiplatelet/anticoagulant
    • chemotherapeutic agents
  35. pathophys of diffuse alveolar damage (VIII).
    alveolar epithelial cells sloughed --> edematous interstitium with chronic inflamm of alveolar walls
  36. s&s of diffuse alveolar damage (viii)
    dyspnea, pulm infiltrate, ARDS
  37. causal agents in diffuse alveolar damage (viii)
    • chemotherapy
    • nitrofurantoin
    • narcotics
    • carbamazepine
  38. when does drug hypersensitivity syndrome (ix) occur?
    within 8 wks of treatment
  39. s&s of drug hypersensitivity syndrome (ix)
    fever, rash, organ involvement (derm, hematol, lymph, pulm)
  40. how does drug hypersensitivity syndrome (ix) present pulmonary disorder?
    • lymphoid interstitial pneumo
    • interstitial lung dz
    • eosinophil pneumo
    • pleural effusion
  41. causal agents of drug hypersensitivity syndrome (ix)
    • aromatic anticonvulsant (esp carbamazepine, phenytoin, phenobarb)
    • allopurinol
    • sulfonamides
  42. differential dx of drug induced pulm disorder?
    • idiopathic pulm fibrosis
    • viral infxn
    • military TB
    • pneumocystis jirovecci
    • SLE
    • wegener's granulomatosis
    • radiation pneumonitis
    • viral bronchiolitis obliterans
  43. risk factors:
    ____ of cytotoxic meds
    combination
  44. risk factors: multiple exposures (increase risk of hypersensitivity rxn).
    which meds?
    • nitrofurantoin
    • sulfasalazine
  45. risk factors: higher dose.
    which meds
    • bleomycin, busulfan, carmustine
    • amiodarone
    • methotrexate
  46. risk factors: increased age.
    which meds?
    • bleomycin
    • nitrofurantoin
  47. risk factor: young age.
    which med
    carmustine
  48. risk factors: radiation therapy and oxygen therapy.
    which meds?
    • bleomycin
    • cyclophosphamide
    • mitomycin
    • carmustine
  49. risk factors of drug-induced pulm disease for bleomycin
    • higher dose
    • increased age
    • radiation/oxygen therapy
  50. risk factors of drug-induced pulm disease for carmustine
    • higher dose
    • young age
    • radiation/oxygen therapy
  51. risk factors of drug-induced pulm disease fornitrofurantoin
    • multiple exposure
    • increased age
  52. morbidity/mortality prognosis of pulm fibrosis
    5 month
  53. morbidity/mortality prognosis of pulm htn
    2-3 yrs from symptom presentation
  54. morbidity/mortality prognosis of carmustine
    15 years
  55. morbidity/mortality prognosis of amiodarone
    • ZERO if early recognition
    • but 64% if untreated!!!
  56. survival may improve with _______.
    early recognition and cessation of therapy
  57. important prevention: do NOT exceed ____.
    toxic dose
  58. what to monitor for amiodarone?
    • CXR and PFT q4-6 mo
    • b/c usually presents with diffuse reticular infiltrates
  59. manage acute pneumonitis/hypersensitive pneumonitis?
    • d/c med
    • prednisone 40-80 mg daily
  60. manage chronic fibrosis
    • d/c med
    • consider prednisone if not improving
  61. manage bleomycin /carmustine-induced pulm tox.
    • avoid high concentration inspired Oxygen (b/c rapid deterioration)
    • corticosteroids (variable response. carmustine generally less inflamm component)
  62. manage methotrexate /amiodarone induced tox.
    • AVOID corticosteroids
    • (may respond but fulminant resp failure has occurred)
  63. manage nitrofurantoin, sulfasalazine tox.
    respond WELL to corticosteroids (b/c hypersensitivity related)
  64. manage alkylating agent, busulfan, mephalan, chlorambucil-induced tox.
    • permanent d/c
    • no corticosteroids
  65. when do you NOT use corticosteroids?
    A) bleomycin
    B) chronic fibrosis
    C) chlorambucil
    D) nitrofurantoin
    C) chlorambucil
    (this multiple choice question has been scrambled)
  66. when do you use corticosteroids?
    A) alkylating agent
    B) methotrexate
    C) sulfasalazine
    D) amiodarone
    C) sulfasalazine
    (this multiple choice question has been scrambled)
  67. when do you use corticosteroids?
    A) melphalan
    B) chlorambucil
    C) carmustine
    D) busulfan
    C) carmustine
    (this multiple choice question has been scrambled)
  68. what does "corticosteroid response" mean?
    improve of sympt of lung fxn within 10 days of therapy
  69. oxygen: what concentration should you use?
    use lowest possible oxygen concentration.
  70. if receiving drug with high incidence of toxicity, early report of S&S is important. what are those?
    • dyspnea on exertion
    • dry non-productive cough
    • acute dyspnea
    • chest pain
  71. drugs commonly cause pulm disorder. list 7
    • amiodraone
    • bleomycin
    • busulfan
    • carmustine
    • methotrexate
    • mitomycin
    • nitrofurantoin
  72. define bronchospasm.
    constriction of the air passages of the lung by spasmodic contraction of the bronchial muscles
  73. define aspirin induced asthma.
    inflamm disease of the airways with exacerbation of pre-existing asthma and rhinitis after ingestion of aspirin and many other NSAIDs
  74. what's samter's triad ("aspirin triad")
    characterized by aspirin sensitivity + asthma + nasal polyposis
  75. what is the highest incidence in aspirin induced asthma. two things that lead a higher risk?
    • bronchospasm
    • asthama and nasal polyps (samter's triad)
  76. beta blocker induced bronchospasm has been fatal with what med?
    opthalm timolol
  77. bronchospasm can also be part of any ___ reaqction. (food, drug, latex, bee sting)
    anaphylaxis
  78. mechanism of aspiring induced asthma.
    • COX enzyme inhibited thus arachidonic acid shifts towards lipoxygenase path. thus more leukotriene and then bronchospasm
    • genetic likely - increased LT synthase (pro-inflam) and dec PG-E2 (anti-inflam)
  79. mechanism of beta-blocker induced bronchoconstriction.
    • may directly inhibit B2-receptor (2 for lungs, 1 for heart)
    • bronchodilator effect of B2 adrenergic compromised
  80. mechanism of ACEi induced cough
    • accum of substance P and bradykinin --> initiate PG and thromboxane A2 pathways
    • substance P: bronchoconstrict
    • bradykinin: stimulate cough reflex
  81. 3 mechanism of sulfite-induced bronchoconstriction
    • 1) direct stimulation of parasympathetic receptors
    • 2) IgE mediated rxn
    • 3) reduced sulfite oxidase (enz to metab sulfur cmpd for excretion)
  82. mechanism of EDTA bronchoconstriction
    • stabilizing agent that chelates calcium
    • can potentiate responsiveness to histamine
  83. mechanism of benzalkonium chloride (BAC) bronchoconstriction
    • found in some nebulizer solutions
    • mast cell degranulation
  84. anaphylaxsis is Ig___ mediated.
    E
  85. which is allergy? (the rest are pseudo and this answer can be pseudo too)
    A) aspirin
    B) sulfite
    C) beta blocker
    D) ACE inhibitor
    B) sulfite
    (this multiple choice question has been scrambled)
  86. EDTA and BAC induced bronchoconstrictions are... pseudo or real allergy
    pseudo allergy
  87. aspirin induced asthma is... pseudo or real allergy?
    pseudo
  88. S&S of bronchospasm
    cough, SOB, wheeze, chest tight
  89. aspirin induced asthma:
    when is onset? what is S&S?
    • onset in third decade
    • persistent rhinitis and nasal congestion.
  90. aspirin induced asthma: when does sensitivity develop?
    within 5 yrs
  91. aspirin induced asthma:
    after exposure, what happens and how soon it happens?
    • acute asthma exacerbation with rhinorrhea, conjunctivitis, flushing within 3 hrs
    • occasional urticaria, periorbital edema, abd pain
  92. aspirin induced asthma: how to make diagnosis
    by oral challenge and monitoring FEV1 and/or sympts
  93. ACEi-induced cough:
    symptoms?
    dry and persistent tickling sensation in the throat
  94. ACEi-induced cough:
    when is the onset?
    • one day to 12 months after initiation.
    • also with increased dose
  95. sulfite induced bronchoconstriction: what are symptoms?
    wheeze, chest tight, dyspnea
  96. latex's clinical presentation.
    • contact dermatitis to anaphylaxis.
    • perform provocation test to confirm dx.
  97. differential dx of asthma and bronchospasm?
    • asthma, COPD,
    • URT, UR obstruction by tumor
    • gastroesophageal reflux
    • laryngeal edema
    • acute left ventricular failure
    • pulmonary emboli
    • chronic bronchitis, eosinophilic pnuemonia
    • systemic vasculitis
  98. risk factors for asthma and bronchospasm?
    • pre-existing hyper-reactive lung disease (i.e. asthma, COPD, cystic fibrosis)
    • (more severe asthma --> more risk drug-induced asthma)
    • this is really important
  99. risk factors of asthma and bronchospasm for NSAID-induced?
    • increased age
    • female
  100. risk factors of ACEi induced cough.
    • African and Asian Am
    • 2 x more in female
  101. is pre-existing hyper-reactive lung disease a risk factor in ACE-i cough?
    NOPE!
  102. manage aspirin induced asthma
    • avoid aspirin and NSAID (b/c this is pseudo allergy thus class effect!) and record
    • if high CV risk, may use desensitization to use asa/nsaid (inc dose over 2-3 day, must use daily). then could take other NSAID
    • may use APAP or corticosteroid instead
    • LT modifier (singulair, accolate) or LT production inhibitor (zileuton) are not conclusively beneficial --> AVOID
  103. when would you use desensitization for aspirin induced asthma?
    when high CV risk because you need to use ASA
  104. can you use LT modifier or production inhibitor if ASA-induced asthma?
    • No, avoid
    • not beneficial
  105. manage b-blocker induced bronchoconstriction
    • use selective b1 adrenergic blocker (atenolol, metoprolol, esmolol, nebivolol)
    • selectivity is dose dependent. do not inc dose w/o consulting doctor
  106. manage ACEi induced cough.
    • d/c med if debilitating - resolves within 1day to 2 wk
    • try to dec dose
    • switch to ARB
    • little evidence to treat cough
  107. after d/c med, when does ACEi induced cough resolve?
    1 day to 2wk
  108. presence of sulfite is required on drug manufacturer product label and foods. t or f
    true!
  109. important risk factor for drug induced bronchospasm (case study)
    prior exposure!
  110. if ASA or NSAID cannot be given for cardioprotection, what can you consider? (case study)
    clopidogrel (Plavix)
  111. random ques: what should formoterol be used with??
    • this is long acting bb.
    • with corticosteroid!
  112. beta 2 and alpha 1 receptor blocker?
    • labetalol
    • carvedilol
  113. albuterol MDI vs. nebulizer.
    what is in nebulizer that may cause bronchospasm?
    benzalkonium chloride
  114. non-selective beta blocker?
    • sotalol
    • propranolol
    • timolol
  115. beta 1 selective blocker
    • metoprolol
    • esmolol
    • atenolol
    • nevibolol
  116. SE of corticosteroid
    • myalgia, myopathy
    • if used >6 mo-1yr, inc glucose, osteoporosis, BP, cataract (inc IOP)
  117. when you have ACE i induced cough, why is it okay to use ARB?
    • b/c ARB do not affect bradykinin
    • ACEi induces bradykinin and substance P

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