Pulm Week 1

What is allergic rhinitis?

inflammation of the nasal mucous membrane

What is allergic rhinitis mediated by?

IgE

When does allergic rhinitis occur?

when inhaled allergenic particles contact mucous membranes and elicit a specific response

What characteristics are associated with allergic rhinitis?

sneezing, nasal itching, watery rhinorrhea, ± nasal congestion; could also be accompanied by itching of the throat, eyes, ears, or palate

True or False: allergic rhinitis is one of the most common diseases affecting adults and children

true

What general symptoms of allergic rhinitis may affect the ability to carry out daily function?

sleep loss, general fatigue, mental fatigue, anxiety/depression, learning disabilities

What other medical conditions are associated with allergic rhinitis?

asthma, chronic rhinosinusitis, otitis media, nasal polyps, respiratory infections, orthodontic issues

What genetic factors play a role in allergic rhinitis?

risk appears to increase incrementally if 1 or 2 parents are atopic

What allergen exposures are related to the etiology of allergic rhinitis?

exposure over time to a protein that elicits the allergic response; many potential AR sufferers are unaware because they never come in contact with the allergen

What role does early microbial exposure have in allergic rhinitis?

may help prevent allergic disease by stimulating a non-atopic immune response; exposure to bacterial endotoxin seems early in life seems to have a protective effect

What other predisposing factors play a role in allergic rhintiis?

elevated serum IgE in childhood, eczema, heavy exposure to secondhand cigarette smoking

What are common indoor allergens?

house dust mite fecal proteins, cockroach fecal proteins, animal dander, mold spores

What are common outdoor allergens?

pollens (tree, grass, shrub), mold spores

What pollen is common in the spring

tree

What pollen is common in the summer

grass

What pollen is common in the fall

ragweed

What are common pollutants in allergic rhinitis?

tobacco smoke, ozone, diesel exhaust

What are common occupational irritants?

wood dust, resin, biologic enzymes, latex, organic dusts

What are the three functions of the nose to prepare incoming gases for the lung?

heats, humidifies, clean

What is the role of cilia in allergic rhintis?

cause some foreign particles to be swallowed and removed via the GI tract

Where do foreign protein material concentrate in allergic rhinitis?

the posterior nasopharynx, where lymph tissue identifies it and produce an allergic antibody response that drives allergic rhinitis

What is the immune response to the first exposure of inhaled allergens?

inhaled allergen enters the nose, allergens are processed by lymphocytes, lymphocytes produce antigen-specific IgE, sensitize the genetically predisposed host to that allergen

What is the immune response to subsequent exposure to inhaled allergens?

inhaled allergen enters the nose, allergen comes in contact with IgE bound to receptors on mast cells, mast cell degranulation and release of inflammatory mediators

What do mast cells release during degranulation of allergic rhinitis?

histamine, leukotrienes (C4/D4), kinins, prostaglandin D2, tryptase

What do the inflammatory mediators cause in allergic rhinitis?

rhinorrhea, itching, sneezing, nasal obstruction, increased nasal secretions and vasodilation

What causes itching in allergic rhintiis?

sensory nerve stimulation

What causes sneezing in allergic rhintiis?

reflex stimulation of the efferent vagal pathways

How fast does the immediate phase reaction occur in allergic rhinitis?

seconds to minutes

How long does it take for the late-phase reaction of allergic rhinitis to occur?

4-8 hours

What occurs in the late phase reaction of allergic rhinitis?

cytokines and t-helper lymphocytes → profound infiltration and activation of migrating cells → inflammatory response

What is responsible for the persistent, chronic symptoms of allergic rhinitis, including nasal congestion?

inflamed mucosa becomes hyper-responsive in the late phase reaction

What does it mean that the mucosa is hyper-responsive?

patient reacts to increasingly lower amounts of allergen; significant increases in nonspecific irritability

Why do we use inhaled therapy in lung diseases?

direct delivery of medication to site of action, in the lungs

What role do SABAs have in asthma therapy?

rescue therapy only

What is the MOAs of SABAs?

stimulate beta-2 receptors in the lungs causing relaxation of bronchial smooth muscle → bronchodilation

What are the side effects of SABAs?

tremor, shakiness, lightheadedness, cough, palpitations, hypokalemia, tachycardia, hyperglycemia

What is the onset of bronchodilation for SABAs?

5-8 minutes

What is the duration of SABAs?

2-6 hours

What brand names of albuterol are MDIs?

ProAir HFA, Proventil HFA, Ventolin HFA, authorized generics

What brand names of albuterol are DPIs?

ProAir RespiClick

What brand names of albuterol are nebulizer solutions?

accuneb, albuterol sulfate solution

What is the usual dosing of albuterol for SOB/resuce?

inhale 2 puffs q4-6h PRN (max of 12 inhalations per day for adults)

What is the usual dosing of albuterol for EIB?

inhale 2 puffs 5-20 minutes prior to exercise

What brand names of levalbuterol are MDIs?

xopenex HFA, generics

What brand names of levalbuterol are nebulizer solutions?

xopenex solution, levalbuterol hydrochloride solution

What is the usual dosing of levalbuterol for SOB/resucue?

inhale 2 puffs q4-6h PRN (max of 12 inhalations per day for adults)

What is the usual dosing of levalbuterol for EIB?

inhale 2 puffs 10-30 minutes before exercise

What medications are inhaled corticosteroids (ICS)?

ciclesonide, fluticasone, beclomethasone, mometasone, budesonide

What’s the brand name of ciclesonide?

alvesco (MDI)

What’s the brand name of beclomethasone?

QVAR (MDI)

What is the brand name of mometasone?

Asmanex: twisthaler (DPI) or HFA (MDI)

What is the brand name of budesonide?

Pulmicort: flexhaler (DPI) or respules (nebulizer)

What are the brand names of fluticasone?

proprinate: Flovent Diskus/HFA, AirDuo Repiclick (DPI)

furoate: Arnuity Ellipta (DPI)

What is the role of ICS in asthma therapy?

the most effective anti-inflammatory medications for asthma

• reduce chronic airway inflammation

  • reduce risk of exacerbations

What are the side effects of ICS?

oropharyngeal candidiasis and dysphonia, growth concerns in young children (but benefits outweigh risks), hyperglycemia, increased risk of fractures

What’s the most important counseling point for ICS?

rinse mouth and spit after each use

True or False: ICS monotherapy is used as maintenance therapy

true

What is the time to maximal benefit of ICS?

3-4 weeks

What is the dosing frequency of ciclesonide?

BID

What is the age range of ciclesonide?

12 years and up

What is the specific MOA of ciclesonide?

gets activated in the lung potentially reducing the side effects caused by ICS in the lung and throat

True or False: you do not need to shake ciclesonide before using

true

What is the dosing frequency of fluticasone propionate?

BID

What is the age range for fluticasone proprionate?

4 years and up

True or False: fluticasone propionate should be shaken before use

true

What is the dosing frequency of fluticasone furoate?

QD

What is the age range of fluticasone furoate?

5 years and up

True or False: fluticasone has a higher risk of sore throat/hoarseness compared to other ICS

true

What is the dosing frequency of beclomethasone?

BID

What kind of MDI is QVAR?

breath-activated

True or False: you should shake beclomethasone before use

false

What is the age range of beclomethasone?

age 4 and up

What is special about beclomethasone?

smaller inhaled particles lead to better lung penetration when compared to other ICS

What is the dosing frequency of mometasone?

QD-BID

What is the age range of mometasone?

ages 4 and up

What is the dosing frequency of budesonide?

QD-BID

What is the age range of Pulmicort respules?

6 months and older

What is the age range of Pulmicort flexhaler?

ages 6 and older

What is the brand name of budesonide/albuterol?

Airsupra

What is the therapy type of airsupra?

rescue therapy only

What is the age range of airspura?

adults

What is the usual dose of AIrsupra?

2 puffs as needed (12 puffs max daily dose)

What class of drugs is not used as monotherapy?

long acting beta agonsits

What is the MOA of LABAs?

stimulates beta 2 receptors in the lungs causing relaxation of bronchial smooth muscle → bronchodilation

What is the onset of bronchodilation of salmeterol (in combo with fluticasone)?

30-60 mins

What is the onset of bronchodilation of formoterol (in combo with budesonide)?

within 3 minutes

What is the onset of bronchodilation of vilanterol (in combo with fluticasone)?

~15 mins

What is the duration of action of salmeterol and formoterol?

12 hours

What is the duration of action of vilanterol?

24 hours

What is the BBW of LABAs?

increased risk of asthma-related death when used as monotherapy in patients with asthma

True or False: LABA monotherapy is NOT recommended for the treatment of asthma

true

What is the brand name of budesonide/ Formoterol?

Symbicort, Breyna

What is the dosing frequency of budesonide/formoterol?

1-2 puffs BID

What is the age range of budesonide/formoterol?

ages 6 and older

What is the role of budesonide/formoterol in asthma therapy?

rescue and/or maintenance

What is the brand name of mometasone/formoterol?

Dulera

What is the dosing frequency of mometasone/ formoterol?

BID

What is the age range of mometasone/formoterol?

ages 5 and older

What is the role of mometasone/formoterol in asthma therapy?

rescue and/or maintenance therapy

What is the brand name of fluticasone propionate/salmeterol?

Advair, Wixela, Airdue