Pulmonary Disorders ACCP/ASHP 2025 Ambulatory Care Pharmacy Preparatory Review and Recertification Course

This set of 200 flashcards covers essential concepts from the Pulmonary Disorders lecture notes, including asthma, COPD, diagnosis, pharmacology, devices, vaccines, smoking cessation, and guideline-based management.

What is asthma?

A chronic inflammatory disorder of the airways with episodic airflow limitation, bronchial hyperresponsiveness, and underlying inflammation causing symptoms like wheezing, breathlessness, cough, and chest tightness.

Name two major asthma phenotypes per GINA/ATS guidance.

Allergic asthma and non-allergic asthma (including adult-onset and obesity-related asthma).

What does FeNO measure?

Fractional exhaled nitric oxide, a noninvasive marker of airway inflammation used as an adjunct in asthma diagnosis/management.

What FeNO value indicates type 2 inflammation likely to respond to corticosteroids in nonsmokers?

FeNO greater than 50 ppb.

What FeNO values suggest possible partial adherence or inadequate control?

FeNO between 25–50 ppb.

What FeNO value suggests ICS exposure or non-type 2 asthma?

FeNO less than 25 ppb.

What is the bronchodilator reversibility criterion for asthma diagnosis?

Increase in FEV1 by ≥12% and ≥200 mL after SABA in patients ≥12 years (≥15% and ≥200 mL in those <12 years).

What is the role of a bronchodilator test in asthma diagnosis?

To demonstrate reversible airway obstruction as part of confirming asthma.

What does EPR-3 refer to in asthma management?

NAEPP Expert Panel Report 3; the guideline used for asthma diagnosis, control, and stepwise therapy.

What is the Global Initiative for Asthma (GINA) guidance generally focused on?

Diagnosis and initial treatment of adults with asthma, COPD features, or overlap; emphasis on ICS/formoterol as reliever and controller in many steps.

What is the purpose of the ATS FeNO guidance?

Provide clinical guidance on FeNO use for diagnosis and response to corticosteroids, with eosinophilic thresholds for adults and children.

What is the baseline spirometry parameter used to differentiate obstructive disease in COPD?

FEV1/FVC ratio is decreased; a post-bronchodilator FEV1/FVC < 70% confirms COPD.

What is GOLD’s staging by FEV1 for airflow limitation?

GOLD 1: ≥80% predicted; GOLD 2: 50–79%; GOLD 3: 30–49%; GOLD 4: <30% predicted.

What is GOLD ABCD assessment based on?

Risk of exacerbations (past events) and symptom burden (CAT or mMRC score) to group patients into A, B, C, or D.

What is recommended initial therapy for GOLD group B?

Dual long-acting bronchodilator therapy (LABA + LAMA) or a single inhaler LABA/LAMA; ICS is considered based on eosinophils.

What is the primary goal of COPD management?

Reduce symptoms and reduce risk by preventing disease progression, exacerbations, and mortality; improve quality of life.

Which vaccines are recommended for COPD patients per CDC guidelines?

Pneumococcal vaccines (PCV15 or PCV20 then PPSV23 where indicated), influenza annually, Tdap if not previously vaccinated, COVID-19 vaccination per CDC, and zoster per GOLD/CDC guidance.

What is the first-line pharmacologic therapy for most asthma patients per 2020 Focused Updates (Step 2)?

Low-dose inhaled corticosteroids (ICS) as controller therapy.

What is SMART in asthma therapy?

Single maintenance and reliever therapy using an ICS/formoterol inhaler; acts as controller and reliever in one inhaler.

What is the preferred ICS/formoterol dose for SMART in patients ≥12 years?

1 or 2 puffs of ICS/formoterol (4.5 mcg/formoterol per puff) every 4 hours as needed, up to a max of 12 puffs per day (54 mcg/day).

What add-on therapy may be considered in asthma Step 5 or 6 for adolescents and adults per GINA/2020 updates?

Tiotropium add-on; biologics for uncontrolled disease; for 6 years and older, tiotropium SMI may be used.

What is FeNO’s role in diagnosing asthma per 2020 Focused Updates?

Adjunctive tool when diagnosis is uncertain or to guide corticosteroid dosing; not a stand-alone diagnostic test.

What influence do blood eosinophils have on COPD therapy decisions?

Higher eosinophils (e.g., >300 cells/µL) predict greater benefit from inhaled corticosteroids (ICS) in COPD.

What is the basic pharmacologic action of a SABA?

Short-acting beta2-agonist that provides quick relief of bronchospasm.

What is the difference between SABA and ICS in asthma treatment?

SABA is a reliever; ICS is a controller aiming to reduce inflammation and prevent symptoms.

What does LAMA stand for and what is its role in asthma?

Long-acting muscarinic antagonist; used as an add-on in certain asthma and COPD scenarios depending on guidelines.

What is the meaning of LTRA in asthma management?

Leukotriene receptor antagonist (e.g., montelukast) used as an add-on or alternative controller in asthma.

What device is a breath-activated MDI with sensors (digital inhaler)?

DigiHaler (Digihaler) – an inhaler with built-in sensors to measure inspiratory flow and use.

What is a spacer holding chamber used for MDIs?

A device that improves total dose delivery by slowing and stabilizing inhalation, reducing oropharyngeal deposition.

What is the purpose of a holding chamber in MDIs?

To improve dose delivery and reduce oropharyngeal deposition; not used with DPIs.

What is the recommended inhaler technique assessment schedule?

Reassess technique at every visit; ensure correct technique with MDIs and DPIs.

What is the purpose of an asthma action plan?

A symptom- or peak-flow-based plan guiding patients on daily management and steps during exacerbations.

What are the three cardinal symptoms that justify antibiotics in COPD exacerbations?

Increased dyspnea, increased sputum volume, and increased sputum purulence.

What is the prednisone (or equivalent) dose for a 5-day COPD exacerbation course?

Prednisone 40 mg daily for 5 days.

What is the typical duration for COPD antibiotic therapy during an exacerbation?

Usually 5–7 days; 5 days often recommended by ACP/Physicians guidance.

Which pathogens are most common in COPD exacerbations?

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis; Pseudomonas more common in severe disease.

What is a common initial COPD management step during a stable phase?

Bronchodilator therapy (e.g., LABA/LAMA combinations) with consideration of ICS based on eosinophils.

What is the GOLD initial treatment for a patient in Group A?

Bronchodilator (SABA or LAMA or LABA) with possible escalation; ICS generally not required.

What is the difference between a DPI and an MDI?

DPI is a dry powder inhaler requiring quick, forceful inhalation; MDI uses a spray and often requires shaking and priming.

What is a common adverse effect of inhaled corticosteroids (ICS)?

Oral candidiasis and hoarseness; rinse mouth after use.

What baseline spirometry result indicates asthma rather than COPD in many cases?

Variable airflow obstruction with reversibility after bronchodilator; not fixed obstruction.

What is the purpose of peak expiratory flow rate (PEFR) monitoring in asthma?

To monitor daily variability and guide action plans and therapy adjustments.

What is the typical FeNO interpretation for diagnosing asthma?

FeNO is adjunct and supportive; a high level supports eosinophilic inflammation but not a definitive diagnosis alone.

What is the role of immunotherapy in mild to moderate allergic asthma (5 years and older)?

Subcutaneous immunotherapy (SCIT) is recommended as adjunctive therapy in mild-to-moderate allergic asthma; SLIT less favored.

What are common counseling strategies for smoking cessation?

5 A’s approach (Ask, Advise, Assess, Assist, Arrange) and motivational interviewing to address readiness and barriers.

What is the effect of combination therapy with ICS/LABA in asthma?

Helps control inflammation and bronchoconstriction; often preferred over high-dose ICS alone in moderate-to-severe asthma.

Explain SMART therapy in asthmatics 12 years and older.

Use ICS/formoterol as both maintenance and reliever therapy, with a specific dosing schedule to reduce exacerbations.

What is the role of tiotropium in asthma management per recent updates?

Tiotropium add-on can be considered in certain moderate-to-severe asthma as an add-on to ICS/LABA; age-specific recommendations vary.

What is the recommended action when FeNO-guided care suggests higher ICS dosing?

Increase ICS dose or add-on therapy when FeNO indicates Type 2 airway inflammation and insufficient control.

What is the recommended vaccination in COPD patients aged 19–64 with chronic lung disease?

One dose of PCV15 or PCV20 followed by PPSV23 at least 1 year later if PCV15 used.

What is the difference between ACO and ACOS terminology in the notes?

ACO (Asthma-COPD Overlap) is the older term; ACOS (Asthma-COPD Overlap Syndrome) is used in some guidelines to describe overlap features.

What is the role of eosinophil counts in choosing COPD therapy?

Blood eosinophils help predict ICS responsiveness; higher counts suggest greater benefit from ICS.

What is an example of a monoclonal antibody used in severe asthma with eosinophilic phenotype?

Mepolizumab (Nucala), or other anti-IL-5/5R agents like benralizumab, reslizumab, and dupilumab.

What is the role of azithromycin in COPD management?

May be used chronically in selected patients to reduce exacerbations, though resistance and other risks exist.

What is the recommended initial dose for albuterol nebulizer therapy in an acute COPD exacerbation?

2.5 mg every 1–4 hours as needed; or 4–8 puffs by MDI with a spacer every 1–4 hours as needed.

What is the purpose of a lung function test like spirometry in asthma/COPD assessment?

To measure FEV1, FVC, and FEV1/FVC to diagnose and monitor control and response to therapy.

What is the primary goal of COPD management regarding vaccinations?

Vaccination against influenza and pneumococcus reduces lower respiratory infections and exacerbations.

Which symptom scale is used to evaluate COPD symptom burden?

CAT (COPD Assessment Test) and CCQ (Clinical COPD Questionnaire).

What is an important non-pharmacologic COPD management strategy?

Pulmonary rehabilitation that includes exercise, nutrition counseling, and disease education.

What is the recommended action if a COPD patient has frequent exacerbations while on LABA/LAMA?

Consider adding ICS if eosinophils are elevated; evaluate for triple therapy (ICS/LABA/LAMA) or other add-ons.

What is the typical management step for EIB (exercise-induced bronchoconstriction)?

Regular physical activity with warm-up; SABA pretreatment; daily controller therapy if symptoms are frequent.

How is a COPD exacerbation classified clinically?

As mild, moderate, or severe based on symptoms and need for therapy or hospitalization; sputum and dyspnea changes guide management.

What substances are commonly assessed to determine antibiotic need in COPD exacerbations?

Three Anthonisen criteria: increased dyspnea, increased sputum volume, and increased sputum purulence.

What is the role of corticosteroids in COPD exacerbations?

Systemic steroids shorten recovery time, improve FEV1 and oxygenation, and reduce treatment failure.

What is a common adverse effect of ICS in COPD patients?

Oral candidiasis and hoarseness; rinse mouth after inhalation.

What is a common first-line rescue therapy for COPD exacerbations?

Short-acting bronchodilators (SABA) with or without SAMA as needed.

What is the role of roflumilast in COPD management?

A PDE-4 inhibitor used in severe COPD with chronic bronchitis to reduce exacerbations in select patients; weight loss and GI effects noted.

Which monoclonal antibody targets IL-4Rα and is used in eosinophilic asthma and some COPD patients?

Dupilumab (Dupixent).

Which monoclonal antibody targets IL-5 and is used in severe eosinophilic asthma?

Mepolizumab (Nucala).

What is the dosing rationale for combination ICS/LABA inhalers?

Provide both anti-inflammatory and bronchodilator effects; reduces exacerbations and improves lung function.

What is the recommended smoking cessation pharmacotherapy for someone with cardiovascular disease where safety is a concern?

Varenicline is often recommended as first-line, with monitoring for neuropsychiatric effects; combinations with NRT may be used in some cases.

What is the 5 A’s framework in tobacco cessation?

Ask, Advise, Assess, Assist, Arrange—the core steps to help patients quit smoking.

What is the role of bupropion in smoking cessation?

Norepinephrine/dopamine reuptake inhibitor used as a smoking cessation aid; second-line option in some guidelines; caution in seizure disorders.

What is the maximum recommended duration for varenicline use in typical guidelines?

Varenicline can be used for up to about 6 months or longer per package instructions, depending on guidance.

What is a common warning associated with varenicline in patients with psychiatric history?

Neuropsychiatric adverse effects; monitor for mood changes; discontinue if worsening depression or suicidality occurs.

What is a common nonpharmacologic smoking cessation strategy?

Behavioral counseling, motivational interviewing, and planning including setting a quit date.

What is the purpose of a “quitting plan” (STAR) in smoking cessation?

Set a quit date, tell family, anticipate challenges, develop coping strategies, and follow-up.

What is the difference between NRT patch and NRT gum in adherence and duration?

Patch offers steady nicotine delivery and better adherence; gum provides quicker relief and can be used PRN with longer-term use possible.

What is the rationale for using ICS/formoterol as a reliever option in GINA track 1?

ICS/formoterol provides anti-inflammatory control at the time of reliever therapy, reducing exacerbation risk versus SABA alone.

What is the recommended action if a patient with asthma has frequent nighttime awakenings but good daytime control?

Upgrade therapy according to EPR-3 stepwise approach, often to add or increase controller therapy.

What is the recommended step for a 8-year-old with moderate persistent asthma per 2020 Focused Updates?

Possible initiation of low-to-mid dose ICS or ICS/LABA depending on age and symptom pattern; screen for appropriate maintenance therapy.

What is the role of selex in the content? (Trick question; not applicable in notes)

Not applicable to this content.

What is the purpose of a holding chamber with masks for young children using MDIs?

To ensure proper inhaled dose delivery when a child cannot coordinate actuation with inhalation.

Which component is part of the Asthma Control Questionnaires?

ACT (Asthma Control Test) and ACQ (Asthma Control Questionnaire) are validated tools.

What is the purpose of a peak flow diary in asthma management?

Track daily PEFR to determine personal best and guide action plans.

What is the role of pneumococcal vaccination in asthma?

Evidence is inconclusive for routine pneumococcal vaccination solely for asthma; guidelines focus vaccination on COPD and other risk factors.

What is the recommended vaccination for influenza in asthma patients?

Annual influenza vaccination to reduce risk of lower respiratory tract infections.

What is the significance of the “SABA overuse” warning in asthma management?

Frequent SABA use (>2 days/week) indicates poor control and the need to escalate controller therapy.

What is the rationale for ICS/formoterol as SMART therapy not FDA-approved in some contexts?

Evidence supports SMART in many guidelines; FDA labeling may vary by product and region, requiring clinician judgment.

What is the significance of a 12-step approach in asthma management?

Step therapy aligns treatment intensity with severity and improves control while minimizing medication exposure.

What is a PEF reading that indicates yellow zone in asthma action plans?

PEFR 50%–79% of personal best; action includes using reliever and stepping up controller as needed.

What does ACT score indicate in asthma?

Asthma Control Test score quantifies control; lower scores indicate not well controlled asthma.

What is a typical ICS daily dose range for beclomethasone MDI?

Variable by product; common low-dose ranges exist (e.g., 40–160 mcg per actuation depending on product).

What is a common side effect of inhaled corticosteroids in children?

Oral candidiasis and potential growth impact with long-term high-dose ICS; monitor growth.

What is the triple therapy in COPD and what does it include?

ICS/LABA/LAMA combination therapy shown to reduce exacerbations in some trials (e.g., IMPACT, ETHOS).

What is the role of azithromycin in COPD during stable disease vs. exacerbation?

Azithromycin can reduce exacerbations in select patients but carries resistance and safety considerations.

Which nonpharmacologic therapy is shown to improve COPD outcomes across severity levels?

Pulmonary rehabilitation including exercise, nutrition, and disease education.

What is the recommended initial step for a patient with GOLD grade 2, group B?

Add a long-acting bronchodilator combination (LABA + LAMA) for dual bronchodilation.

What is the significance of the BODE index in COPD?

A composite index (Body mass, Obstruction, Dyspnea, Exercise capacity) used to assess prognosis; not explicitly in notes but part of COPD assessment context.

What is the main purpose of the 2025 GOLD report?

Provide updated global guidance on COPD diagnosis, management, and prevention.