Pulmonary conditions and Tobacco cessation

What is Pulmonary Hypertension?

High blood prsssure in the pulmonary arteries : mPAP >25

What are drugs that can cause pulmonary hypertension?

Cocaine, amphetamines

SSRI’s in pregnancy

Wt loss drugs like phentermine

What is increased and what is decreased in pulmonary hypertension?

Increased vasoconstrictors: Endothelin, and TxA2

Decreased vasodialators: Prostacylcin

What is the most common cause of death in patients with Pulmonary hypertension?

Right sided heart failure (fatigue and dyspnea is associated.)

Non-drug treatment of pulmonary hypertension

Sodium restriction <2.4 grams

Avoid NSAIDS

Receive Influenza and Pneumococcal vaccine.

How is the PAH diagnosed?

A right heart catheterization, and a vasoactive test.

1) A positive vasoactive test indicates treatment with_____ 2) A negative vasoreactive test indicates treatment with ____

1) CCB’s

2) Endothelin antagonists, Prostacyclin analogues, PDE5i, and sGC

What are the Prostacyclin analogues? SE? DOSE?

Epoprostenol (Flolan)

Treprostinil

Iloprost

SE:

• Vasodilator (Hypotension, flushing, HA.)

• Rebound PH

• JAW PAIN

• AVOID ABRUPT DISCONTINUATION

• Protect from light, and Flolan needs ice packs after reconstitution

DOSE: 2ng/kg/min

What are the endothelin anatgonists?

Bosentan (Tracleer)

SE:

• Teratogenic, needs contraceptives

• Hepatotoxic

• Decreased HGB, HA.

What are the PDE5i’s?

MOA?

C/I?:

SE?

Sildenafil (Revatio)

Tadafil (Adcrica)

MOA: Increased cGMP→ Vasodialation

C/I: Nitrates

SE: hearing loss and vision loss

What are the sGC’s?

BW?

Riociguat

BW: TEratogenic, requires a pregnancy test like Bosentan

HAS SO MANY DRUG INTRERACTIONS (pde5i, nitrates)

What meds cause Pulmonary Fibrosis?

Amiodarone and Dronedarone

Bleomycin

Buslfan

Carmustine

What is asthma?

Inflammation and bronchoconstriction of the lungs, with difficulty exhaling.

Classic asthma symptoms?

Wheezing, sob, chest tightness, coughing

Common triggers of asthma?

Pollen, dust, mites

Obesity, stress, gerd

Pollution, Cigarettes

Perfume and cosmetics

Cold air and wether change

Drugs: NSAIDS, Asprin, non selective beta blockers

What is the differnce between FEV1, FVC and FEV1/FVC

FEV1: Forced expiratory volume in 1 second

FVC: maximum air forced out after a deep breath

FEV1/FVC: the percent of air capacity that can be exhaled in one second

Whatb is the asthma diagnosis?

Measure the FEV1 with spirometry → give albuterol→ Measure post bronchodialator FEV1.

If FEV1 > 12% post bronchodialation it is ASTHMA.

Explain step 1- step 5 of the asthma assessment

Step 1: < 2 exaccerbations a month

Step 2: > 2 a month (<4 a week)

Step 3: Most days, 1 or more night-time awakening a week

Step 4 and 5: Daily, 1 or more night-time awakening a week

What vaccines are recommended for Asthma?

Pneumococcal and Influenza

What is the preffered rescue inhaler?

ICS + formoterol

Can also use a saba (albuterol)

What are then controller asthma meds

ICS

LABA’s

LAMA’s

LTRA’s

Theophyline

mAB’s Omalizumab (Sever allergic asthma ), Everything else is eosinophillic asthma

What are the treatments for each step of Asthma

Steps	Rescue Inhaler	Maintenance
Step 1	PRN ICS + Formoterol ICS + SABA
Step 2	ICS +formoterol Saba ICS + saba	ICS
Step 3	ICS +formoterol Saba ICS + saba	Low dose ICS +formoterol Low dose ICS + LABA
Step 4	ICS +formoterol Saba ICS + saba	Med dose ICS +formoterol Med dose ICS + LABA
Step 5	ICS +formoterol Saba ICS + saba	High dose ICS +formoterol High dose ICS + LABA

What are the beta 2 agonists used in Asthma?

Albuterol (Proventil HFA, ProAir HFA, ProAir Respiclick, Ventolin HFA)

• 90mcg/inh

• 200 inhlations

SE of beta 2 agonists?, Which version has less SE?

Nervousness, hypokalemia, tachycardia, palpitations, tremors, cough, hyperglycemia

Less Side effects is the R- isomer: Levoalbuterol

What is the LABA’s used in asthma?

Seveer BW?

Salmuterol (Servent Diskus)

ASTHMA RELATED DEATH IF USED AS MONO-THERAPY

What are the corticosteroids used in Asthma?

Budesonide (Pulmicort)

Fluticasone (Arnuity Elipta)

Beclemethasone (QVAR RediHaler)

Mometasone

Warnings of corticosteroids?

Pulmicort respules usage group?

Do not shake?

Growth retardation, bone fractures

SE; Dysphonia, oral candasis(thrush), cough

• decrease thrush with spacer and rinsing mouth

Pulmicort respules usage group? Kids

Do not shake Qvar Redihaler, Alvesco

What are the controller maintenacne inhalers in asthma

ICS

• Budesonide (pulmicort)

• Fluticasone (arnuity elipta)

• Beclometasone (QVAR RediHaler)

• Mometasone

LABA’s

• Salmeterol (Servent Diskus)

LAMA’s

• Tiotropium (Spiriva Respimat)

ICS+ LABA

• Budesonide + formoterol (Symbicort)

• Fluticasone + salmetrerol (Advair, Breyna)

• Mometasone, Formoterol (Dulera)

• Fluticasone + vilanterol (Breo Ellipta)

LAMA/LABA/ICS

• Umeclidinium/vilanterol/fluticasone (Trelegy Elipta)