13 - Medications for Asthma and COPD

treatment of asthma

• reduce impairment

  • prevent symptoms

  • maintain normal/near normal function, infrequent use of SABA

  • maintain normal activity levels

  • meet patient’s and family’s expectations of satisfaction with care

• reduce risk

  • prevent exacerbations

  • provide optimal pharmacotherapy with few/no side effects

  • prevent progressive loss of lung function

levels of asthma severity

• intermittent

• ≤ 2 symptoms/week

• ≤ 2 nocturnal attacks/month

• PEF ≥ 80% of best

• PEF variability < 20%

levels of asthma severity

• mild persistent

• 3-6 symptoms/week

• > 2 nocturnal attacks/month

• PEF ≥ 80% of best

• PEF variability 20-30%

levels of asthma severity

• moderate persistent

• symptoms daily

• > 1 nocturnal attack/week

• PEF 60-80% of best

• PEF variability > 30%

levels of asthma severity

• severe persistent

• symptoms continuous

• frequent nocturnal attacks

• PEF ≤ 60% of best

• PEF variability > 30%

hospitalization for asthma

1. quick relief meds via MDI/SVN

   • SVN if pulmonary function < 50% predicted

2. if hypoxemic, use supplemental O₂

3. if symptoms persist, use systemic steroids and anticholinergic agents

4. can add inhaled/IV magnesium sulfate and aggressive O₂ therapy

5. discharge when pulmonary function returns to 70% predicted range

α₁-antitrypsin (α₁-AT)

glycoprotein found in extra-/intracellular fluid

• protects lungs against proteases

• deficiency causes early onset emphysema (age 40s-50s)

• normal: 150-350 mg/dL

• deficiency: < 80 mg/dL

signs and symptoms of emphysema

• dyspnea on exertion

• non-productive cough

• “pink puffer” appearance due to accessory muscle use

• weight loss due to WOB

chronic bronchitis

inflammation of the bronchioles

• increased size and number of mucus glands

• narrow small airways

• episodes usually due to respiratory tract infections

manifestations of chronic bronchitis

• productive cough in the morning

• wheezing

• barrel chest

5 A’s of smoking cessation

1. Ask

2. Advise

3. Assess

4. Assist

5. Arrange

Fagerstrom Test for Nicotine Dependence (FTND)

tool used for measuring nicotine addiction

• score of 6+ = high dependence

nicotine replacement therapy (NRT)

• nicotine patch

• nicotine gum/lozenge

• nicotine nasal spray

• nicotine oral inhaler

varenicline (Chantix)

drug that is partial antagonist of nicotinic acetylcholine receptor

• binds to and stimulates receptor, reducing craving

• may block inhaled nicotine from working

vaccines to reduce COPD morbidity/mortality

• influenza vaccine

• pneumococcal vaccine

• Pneumovax

COPD treatment goals

GOLD guidelines

• assess and monitor disease

• reduce risk factors

• manage stable disease

• manage exacerbations

COPD severity

• stage I: mild

• FEV₁/FVC < 70%

• FEV₁ ≥ 80% predicted

COPD severity

• stage II: moderate

• FEV₁/FVC < 70%

• FEV₁ 50-80% predicted

COPD severity

• stage III: severe

• FEV₁/FVC < 70%

• FEV₁ 30-50% predicted

COPD severity

• stage IV: very severe

• FEV₁/FVC < 70%

• FEV₁ < 30% predicted or 50% predicted + chronic respiratory failure

drugs to treat COPD

• β₂-agonists and anticholinergics

β₂-agonists

• cause less bronchodilation in COPD than in asthma

anticholinergics

• COPD responds better to these than asthma

both

• albuterol-ipratropium (Combivent) can simplify therapy

drugs to treat COPD

• theophylline

drug not commonly used, for patients who can’t use MDI

• improves respiratory muscle function

• stimulates respiratory center

• enhances ADLs

drugs to treat COPD

• anti-inflammatory drugs

drugs have less benefit for COPD

drugs to treat COPD

• inhaled corticosteroids

drugs are good for stage III and IV of COPD

drugs to treat COPD

• oral corticosteroids

drugs for moderate-to-severe COPD exacerbations

• side effects: skin damage, cataracts, DM, osteoporosis, gastric ulceration

drugs to treat COPD

• mucokinetics

these drugs have little info on COPD benefits

drugs to treat COPD

• oxygen

agent that maintains normal P_aO₂ and decreases WOB with COPD

drugs to treat COPD

• antibiotics

drugs to treat COPD exacerbation and sputum

• common bacteria:

  • S. pneumoniae

  • H. influenzae

  • M. catarrhalis

drugs to treat COPD

• α₁-antitripsin (α₁-AT) therapy

drugs that treat emphysema caused by α₁-AT deficiency

• α₁-proteinase inhibitors

  • Prolastin

  • Aralast

  • Zemaira

• weekly IV infusions

• costly

therapy for each stage of COPD

• stage 0

• avoid risk factors

• flu vaccine

therapy for each stage of COPD

• stage I

• therapy for stage 0

• short-acting bronchodilator as needed

therapy for each stage of COPD

• stage II

• therapy for stages 0-I

• 1 or more long-acting bronchodilators

• rehab

therapy for each stage of COPD

• stage III

• therapy for stages 0-II

• inhaled corticosteroids if multiple exacerbations

therapy for each stage of COPD

• stage IV

• therapy for stages 0-III

• long-term O₂ if chronic respiratory failure