T5 - IE2 - Pulmonology - Munjy + Ostrom - Integrated Asthma Week 5

At risk patients for asthma exacerbations

Newly diagnosed patents without control medications

Patients on the wrong step therapy

Exposure to triggers

- allergens

- environmental triggers

- pollution

Well controlled patients on long term control medications with acute illness

- respiratory infections (rhinovirus, influenza, pneumonia, bronchitis)

At risk patients for asthma exacerbations: ________ diagnosed patients without _______ medications

- Newly (diagnosed patients)

- (without) control

At risk patients for asthma exacerbations: Patients on the ________ step therapy

- wrong (step therapy)

At risk patients for asthma exacerbations: exposure to triggers

allergens

environmental triggers

pollution

At risk patients for asthma exacerbations: well controlled patients on _____ ______ control medications with _____ illness

- long term (control)

- acute (illness)

e.g., respiratory infections (rhinovirus, influenza, pneumonia, bronchitis)

At risk patients for asthma exacerbations: well controlled patients on long term control medications with acute illness

respiratory infections

- rhinovirus

- influenza

- pneumonia

- bronchitis

Factors that can trigger asthma figure

Ways to decrease risk of exacerbations

allergy testing if clear relationship present

removal of carpets

removal animal hair, avoid in bedroom

frequent cleaning

reduction of humidity (dehumidifier or AC)

avoid irritants such as smoke, strong smells / odors

cockroaches

- allergy to droppings and remains from cockroaches

- hygiene

Ways to decrease risk of exacerbations: allergy testing if _______ _________ present

- (allergy testing if) clear relationship

Ways to decrease risk of exacerbations: removal of __________ and/or _________ hair (i.e., for pets avoid in ________)

- (removal of) carpets

- animal (hair)

- (avoid in) bedroom

Ways to decrease risk of exacerbations: ____________ cleaning

- frequent (cleaning)

Ways to decrease risk of exacerbations: __________ of humidity

- reduction (of humidity)

e.g., dehumidifier or AC

Ways to decrease risk of exacerbations: avoid irritants such as...

smoke

strong smells / odors

Ways to decrease risk of exacerbations: cockroaches

allergy to droppings and remains from cockroaches

hygiene

Exercise and asthma: exercise induced bronchospasm can ________ ability to function

- limit (ability to function)

Exercise and asthma: _________ ___ before exercise

- warm up (before exercise)

Exercise and asthma: work-out _________ if poor air quality, cold weather

- indoors (if poor air quality, cold weather)

Exercise and asthma: workout indoors if ______ air quality, _____ weather

- poor (air quality)

- cold (weather)

Exercise and asthma: talk to provider about ____________ medication

- prophylactic (medication)

Exercise and asthma: prophylactic medications

SABA: 2 inhalations 5 minutes before exercise (2-3 hour response)

LABA: chronic use discouraged but may provide benefit for up to 12 hours

Cromolyn: not as effective

Exercise and asthma - prophylactic medications: SABA, ____ inhalations, ___ minutes before exercise

- 2 (inhalations)

- 5 (minutes before exercise)

2-3 hour response

Exercise and asthma - prophylactic medications: LABA, _________ use discouraged but may provide benefit for up to ____ hours

- chronic (use)

- 12 (hours)

Exercise and asthma - prophylactic medications: cromolyn

not as effective

Other factors that can make asthma worse - GERD

reflux of gastrointestinal fluid can lead to worsening of symptoms, inflammation and increased cough / sputum

Manage appropriately with diet, exercise, weight loss and medication if indicated

Other factors that can make asthma worse - GERD: reflux of ____________ fluid can lead to __________ of symptoms, ______________ and increased ______ / ________

- (reflux of) gastrointestinal (fluid)

- worsening (of symptoms)

- inflammation

- cough / sputum

Other factors that can make asthma worse - GERD: manage appropriately with _____, ____________, ______ loss, and ________ if needed

- diet

- exercise

- weight (loss)

- medication (if needed)

Other factors that can make asthma worse - obstructive sleep apnea

Increased shortness of breath

Nighttime awakenings

Refer to pulmonologist for further evaluation

Other factors that can make asthma worse - obstructive sleep apnea: increased _____________ of breath

- shortness (of breath)

Other factors that can make asthma worse - obstructive sleep apnea: nighttime ____________

- (nighttime) awakenings

Other factors that can make asthma worse - obstructive sleep apnea: refer to ___________ for further evaluation

- pulmonologist (for further evaluation)

Other factors that can make asthma worse - rhinitis

post-nasal drip

increased inflammatory response

Other factors that can make asthma worse - rhinitis: ______-______ drip

- post-nasal (drip)

Other factors that can make asthma worse - rhinitis: increased _____________ response

- (increased) inflammatory

Short-acting medications for asthma

SABA

- albuterol

- levalbuterol

Anticholinergics

- ipratropium

Systemic corticosteroids

Short-acting medications for asthma: SABA drugs

albuterol

levalbuterol

Short-acting medications for asthma: SABA (albuterol, levalbuterol)

agonism at the β-2 receptor results in dilation of the bronchial smooth muscle and relaxation thereby relieving shortness of breath.

Adverse effects: β-receptor effects are not fully limited to the beta-2 receptor and therefore can cause tachycardia

(action on beta-1 receptors on heart) and nervousness (adrenergic stimulation).

Short-acting medications for asthma - SABA (albuterol, levalbuterol): _________ at the β-2 receptor results in ________ of the bronchial smooth muscle and __________ thereby relieving shortness of breath.

- agonist (at the β-2 receptor)

- dilation (of the bronchial smooth muscle)

- relaxation

Short-acting medications for asthma - SABA (albuterol, levalbuterol): agonism at the ___-___ receptor results in dilation of the ____________ ________ _______ and relaxation thereby ________ shortness of breath.

- β-2 (receptor)

- bronchial smooth muscle

- relieving (shortness of breath)

Short-acting medications for asthma - SABA (albuterol, levalbuterol): adverse effects; β-receptor effects are _____ _____ _____ to the β-2 receptor and therefore can cause __________ (with action on the β-1 receptors on the heart) and ____________ (adrenergic stimulation)

- not fully limited (to the β-2 receptor)

- tachycardia

- nervousness

Short-acting medications for asthma - anticholinergic drugs

Ipratropium

Short-acting medications for asthma - anticholinergic: ipratropium

blocks acetylcholine from constricting bronchial smooth muscle thereby causing bronchodilation

adverse effects: systemic anticholinergic effects acne occur, especially with long-term use (tachycardia noted intervals)

Short-acting medications for asthma - anticholinergic (ipratropium): blocks _________ from constricting ________ ________ _________ thereby causing bronchodilation

- (blocks) acetylcholine

- (constricting) bronchiolar smooth muscle

Short-acting medications for asthma - anticholinergic (ipratropium): ______ acetylcholine from ________ bronchiolar smooth muscle thereby causing _____________

- blocks (acetylcholine)

- constricting (bronchiolar smooth muscle)

- bronchodilation

Short-acting medications for asthma - anticholinergic (ipratropium): adverse effects; __________ anticholinergic effects can occur, especially with ______-______ use

- systemic (anticholinergic effect)

- long-term (use)

i.e., tachycardia noted in trials

Short-acting medications for asthma - systemic corticosteroids

Anti-inflammatory action that suppresses action of cytokines,

airway eosinophils, and release of inflammatory mediators.

Indicated for short term use for moderate to severe exacerbations

Short-acting medications for asthma - systemic corticosteroids: _______-________ action that suppresses action of cytokines, airway eosinophils and __________ of inflammatory mediators

- anti-inflammatory (action)

- release (of inflammatory mediators)

Short-acting medications for asthma - systemic corticosteroids: Anti-inflammatory action that suppresses action of _________,

_______ ___________, and release of _________ _________.

- (action of) cytokines

- airway eosinophils

- inflammatory mediators

Short-acting medications for asthma - systemic corticosteroids: indicated for short term use for ________ to ________ exacerbations

- (for) moderate

- severe (exacerbations)

Long-acting control medications for asthma - ICS drugs

beclomethasone

budesonide

ciclesonide

flunisolide

fluticasone

mometasone

Long-acting control medications for asthma - ICS drugs: is the treatment of ________ for long-term ________ of asthma

- (treatment of) choice

- (long-term) control

Long-acting control medications for asthma - ICS drugs: reduces _______ of symptoms, _______ control, decreases risk of _________, reduces risk of __________, reduces need for ________ corticosteroids, improves ______ _______ tests, _________ morbidity and mortality

- severity (of symptoms)

- improves (control)

- (decreases risk of) exacerbations

- (risk of) hospitalizations

- (reduces need for) systemic

- lung function (tests)

- decreases (morbidity and mortality)

Long-acting control medications for asthma - ICS drugs: anti-inflammatory action that ________ action of cytokines, _______ eosinophils, and release of _________ mediators

- suppresses (action)

- airway (eosinophils)

- inflammatory (mediators)

Long-acting control medications for asthma - ICS drugs: symptoms improve within __-___ weeks with maximal effect at __-___ weeks

- 1-2 (weeks)

- 4-8 (weeks)

Long-acting control medications for asthma - ICS drugs side effects

oral candidiasis (thrush) - most common

dysphonia (5-50%)

Long-acting control medications for asthma - ICS drugs side effects; oral candidiasis (thrush) is the ______ ______ adverse effect due to residual steroid in the oral mucosa. Counsel patients to _______ mouth after use and/or use _______, holding chamber to ensure dose of steroid reaches ______ and not oral mucosa

- most common (adverse effect)

- rinse (mouth after use)

- spacer

- airway (and not oral mucosa)

Long-acting control medications for asthma - ICS drugs side effects: dysphonia; _______ in speech, change in ______ of voice, associated with ______ dosages and can be reduced with use of ________, ______ chamber

- difficulty (in speech)

- (change in) tone

- increased (dosages)

- spacer

- holding (chamber)

Long-acting control medications for asthma - LABA drugs

salmeterol

formoterol

Long-acting control medications for asthma - LABA (salmerterol, formoterol): agonist at the __-___ receptor with _________ duration of action leading to ___________ bronchodilation

- β-2 (receptor)

- extended (duration)

- prolonged (bronchodilation)

BBW: NOT USED as mono therapy due to increased risk of asthma related death. Never use a LABA without combination of an ICS

Long-acting control medications for asthma - LABA (salmerterol, formoterol): BBW

NOT USED as mono therapy due to increased risk of asthma related death. Never use a LABA without combination of an ICS

Long-acting control medications for asthma - LABA (salmerterol, formoterol): side effects

similar to SABA

tachycardia, adrenergic effects, occurs at higher dosing range

Long-acting control medications for asthma - leukotriene modifier drugs (leukotriene receptor antagonists)

Montelukast

Zafirlukast

Long-acting control medications for asthma - leukotriene modifier drugs (5-lipooxygenase inhibitor)

Zileuton

Long-acting control medications for asthma - leukotriene modifier drugs (leukotriene receptor antagonists - montelukast, zafirlukast): block the action of leukotrienes which are _______ __________ mediators that lead to airway constriction, mucus production, and _________ vascular permeability

- potent inflammatory (mediators)

- increased (vascular permeability)

Long-acting control medications for asthma - leukotriene modifier drugs (leukotriene receptor antagonists - montelukast, zafirlukast): block the action of leukotrienes which are potent inflammatory mediators that lead to airway __________, _______ production, and increased __________ __________

- (airway) constriction

- mucus (production)

- (increased) vascular permeability

Long-acting control medications for asthma - leukotriene modifier drugs (leukotriene receptor antagonists - montelukast, zafirlukast): used as _________ therapy, and _____ first-line

- adjunct (therapy)

- NOT (first-line)

Long-acting control medications for asthma - leukotriene modifier drugs (leukotriene receptor antagonists - montelukast, zafirlukast): side effects

rare incidents of eosinophilia and vasculitis

Monitor for neuropsychiatric effects

- behavioral changes

- insomnia

- memory disturbances

- suicidal ideations

Hepatic dysfunction is a concern (do not use in patients with hepatic dysfunction)

Long-acting control medications for asthma - leukotriene modifier drugs (5-lipooxygenase inhibitors - Zileuton): ___________ the enzyme that catalyzes the formation of ___________ from ____________ acid

- inhibiting (the enzyme)

- leukotrienes

- arachidonic (acid)

Used as adjunct therapy, not-first line

Long-acting control medications for asthma - leukotriene modifier drugs (5-lipooxygenase inhibitors - Zileuton): used as adjunct _______, not _______-_____

- (adjunct) therapy

- not (first-line)

Long-acting control medications for asthma - leukotriene modifier drugs (5-lipooxygenase inhibitors - Zileuton): adverse effects

diarrhea

indigestion

nausea

dizziness

headache

insomnia

Uncommon but serious

- hepatotoxicity

- aggressive behavior

- agitation

- dream disorder

- hallucinations

- suicidal ideations

Long-acting control medications for asthma - methylxanthine drugs

theophylline

Long-acting control medications for asthma - methylxanthine (theophylline): _____-_______ __________ _____ that leads to smooth muscle relaxation as well as suppression of airway stimuli

- non-selective phosphodiesterase inhibitor (that leads to smooth muscle)

Long-acting control medications for asthma - methylxanthine (theophylline): non-selective phosphodiesterase inhibitor that leads to smooth muscle __________ as well as suppression of airway __________

- (smooth muscle) relaxation

- (suppression of airway) stimuli

Long-acting control medications for asthma - methylxanthine (theophylline): used as _________ therapy, not first-line; levels must be monitored due to _______ therapeutic monitoring. Must remain between __-___ mcg/mL at steady state and should be monitored regularly

- adjunct (therapy)

- narrow (therapeutic monitoring)

- 5-15 (mcg/mL)

Long-acting control medications for asthma - methylxanthine (theophylline): side effects

N/V

headache

insomnia

tremor

irritability

restlessness

serious side effects

- atrial fibrillation

- tachyarrhythmias

- intracranial hemorrhage

- seizures

Long-acting control medications for asthma - mast cell stabilizer drugs

cromolyn sodium

Long-acting control medications for asthma - mast cell stabilizer (cromolyn sodium): ___________ mast cells and anti-inflammatory agent that prevents ____________ in response to an inhaled _______

- stabilizes (mast cells)

- (prevents) bronchoconstriction

- (inhaled) allergen

Long-acting control medications for asthma - mast cell stabilizer (cromolyn sodium): used as ________ therapy, not ______-line

- adjunct (therapy)

- (not) first(-line)

Long-acting control medications for asthma - mast cell stabilizer (cromolyn sodium): side effects; _______ _______ in mouth, diarrhea (oral solution); headache, burning sensation in _____, ________ (inhalation powder)

- bad taste (in mouth)

- (burning sensation in) eye

- cough

May cause immunologic reactions such as anaphylaxis or hypersensitivity reaction (rare)

Long-acting control medications for asthma - immunomodulator drugs

Omalizumab

Long-acting control medications for asthma - immunomodulator (Omalizumab): recombinant, humanized, monoclonal antibody directed against _______.

In asthma, inhibits the binding of ____ to its receptor on mast cells and basophils thereby decreasing the amount of _____________ mediators that are released

- IgE

- IgE

- inflammatory (mediators that are released)

Long-acting control medications for asthma - immunomodulator (Omalizumab): recombinant, humanized, monoclonal antibody directed against IgE.

In asthma, inhibits the ___________ of IgE to its receptor on ______ ______ and __________ thereby decreasing the amount of inflammatory mediators that are _________

- (inhibits the) binding

- mast cells

- basophils

- (inflammatory mediators that are) released

Long-acting control medications for asthma - immunomodulator (Omalizumab): ___ levels must be determined before dose is __________

- IgE (levels must be determined)

- established

Long-acting control medications for asthma - immunomodulator (Omalizumab): Side effects

injection site reactions

arthralgias

headache

nasopharyngitis

sinusitis

chronic idiopathic urticaria

fever

pain

Rare and severe side effects

- MI

- TIA

- PE

- pulmonary hypertension

Long-acting control medications for asthma - immunomodulator (Omalizumab): BBW

Anaphylaxis may occur

Patients should be monitored for the first 3 doses

Advise patients to seek emergency medical attention if signs / symptoms of anaphylaxis occur

Patient counseling upon discharge: __________ ______ of _____ corticosteroids for acute exacerbation

- burst therapy

- oral (corticosteroids)

Patient counseling upon discharge: appropriate use of __________ to avoid side effects and receive dose appropriately

- (appropriate use of) inhaler

Patient counseling upon discharge: use of SABA _____ to exercise and ____ _______ unless needed

- (SABA) prior (to exercise)

- NOT after (unless needed)

Patient counseling upon discharge: avoidance of ________

- (avoidance of) triggers

Patient counseling upon discharge: avoid ________, __________, and ___________ smoke

- allergens

- smoking

- secondhand (smoke)