Pulmonary Disorders & Management - 4

What are major "obstructive lung diseases?

asthma and COPD

What does COPD stand for?

chronic obstructive pulmonary disorder

What form of medication is most preferred for pulmonary issues? Why?

inhaled, nebulized, or spray meds because they directly reach the targeted tissues and minimize adverse systemic effects

What may be damaged in the lungs in a PT with COPD?

• the septa between alveoli can be destroyed

• a pulmonary bleb may form

How many PT are affected by asthma in the US?

25 million

Asthma is the most common ____ disease in childhood

chronic

Asthma usually begins in ______ and can ______ as they age

childhood, improve

What can asthma be described as?

a chronic reversible inflammatory disease characterized by acute exacerbations

Between exacerbations, what occurs in PT with asthma?

minimal symptoms and signs

What can asthma exacerbations triggered by?

• viral URIs

• allergen exposure

• exercise

• stress

Presentation of asthma exacerbations

• cough

• chest tightness

• SOB

• tachypnea

• wheezing

What causes airway obstruction during asthma exacerbations?

• inflammation of the bronchial wall

• bronchorrhea (increased mucus secretion)

• bronchial smooth muscle constriction

What does airway obstruction in asthma result in?

alveolar hyperexpansion → trouble getting air out

What can form during exacerbations and cause a “ball-valve”?

mucus plug that moves to allow air in, but covers entrance to alveoli to not allow air out during expiration, resulting in alveolar hyperexpansion

What can be observed in the pulmonary lining during an asthma attack?

• more mucus formed

• more inflammatory cells present

• more glands

• thicker walls

• less lumen

• less gas exchange

What are the objectives of asthma therapy?

• maximize PT ability to lead normal lifestyles

• minimize frequency and severity of exacerbations

• effectively treat acute exacerbations

• minimize the risk of developing irreversible disease

What does medical therapy of asthma involve?

• controller therapy (management between exacerbations)

• rescue therapy (treating acute exacerbations)

What percentage of the population is affected by COPD?

5%

What does COPD result in?

progressive airway obstruction

What are the different types of COPD?

• chronic bronchitis (blue bloater)

• emphysema (pink puffer)

What is the primary factor in the development of COPD?

tobacco abuse

What does a PT with COPD often have?

multiple co-morbidities

What occurs in a PT with COPD regarding symptoms compared to a PT with asthma?

PT with COPD are often symptomatic between exacerbations

What type of components are associated with COPD?

irreversible components

In COPD, what does antigen exposure result in?

• ciliary dysfunction

• bronchial wall thickening

• bronchorrhea (excess mucus production)

• smooth muscle constriction (bronchospasm)

What does obstruction in COPD result in?

hyperexpanded airways, “trouble getting air out”

What is part of the pulmonary system is destroyed in COPD and what does it lead to?

irreversible destruction of the alveolar walls (interstitium) leading to the development of blebs and bullae

What are the goals of controller meds in asthma?

• maximize quality of life

• minimize severity of exacerbations (everyone gets URI’s)

• avoid progression to irreversible disease

What are examples of controller meds for asthma?

• inhaler corticosteroids (ICS)

• inhaled long-acting beta-2-agonists (LABA)

  • used only in combination with ICS

• inhaled long-acting muscarinic antagonists (LAMA)

• oral corticosteroids

• oral methylxanthines

What are examples of rescue meds for asthma?

• inhaled or nebulized short-acting beta-2-agonists (SABA)

  • sympathomimetics

• inhaled or nebulized short-acting muscarinic antagonists (SAMA)

  • anticholinergics

• combination SABA + SAMA

• inhaled corticosteroids

• systemic corticosteroids (oral or parenteral)

What can steroids be used in regarding asthma?

both controller and rescue meds

What are examples for controller meds for COPD?

• inhaled corticosteriods (ICS)

  • systemic steriods avoided

• inhaled long-acting beta-2-agonists (LABA)

  • increases sympathetic

• inhaled long-acting muscarinic antagonists (LAMA)

  • decreases parasympathetic

• combined ICS + LABA, combined LABA + LAMA, combined ICS + LABA + LAMA

• oral methylxanthines

What are examples of rescue meds for COPD?

• inhaled or nebulized short-acting beta-2-agonists (SABA)

• inhaled or nebulized short-acting muscarinic antagonists (SAMA)

• inhaled or nebulzied combination of SABA + SAMA

• systemic corticosteriods

What medication is generally avoided as a controller therapy for COPD? Why?

systemic steroids due to significant side effects and multiple PT co-morbidities

Function of ICS for asmtha and COPD

• decreased inflammation

• decreased airway’s hyper-responsiveness to triggers

• decreased bronchorrhea (mucus production)

How long may it take ICS meds to take effect?

weeks to months

What are examples of ICS meds for asthma and COPD and their suffix?

• fluticasone (Flovent)

• beclomethasone (QVAR)

• budesonide (Pulmicort)

-ASONE

What must a PT taking ICS do after use of meds?

rinse mouth to prevent oral thrush

What does LABA controller meds result in for COPD?

smooth muscle relaxation (sympathomimetic)

How may LABA meds be used for COPD?

alone or in combination with inhaled steroids

In asthma, when can LABA meds be used?

only in combination with ICS, cannot be used alone

Examples of LABA meds in COPD and their suffix

• salmeterol (Serevent)

• formoterol (Foradil)

-TEROL

What is the black-box warning associated with LABA meds?

• increase in asthma-related deaths in PT treated solely with LABA

  • need to be paired with ICS in asthma

  • can be used as single therapy in COPD

What does combined ICS + LABA meds result in for asthma and COPD?

• anti-inflammatory effects

• decreased bronchorrhea (mucus production)

• smooth muscle relaxation (bronchodilation)

Examples of combined ICS + LABA meds for asthma and COPD

• budesonide + formoterol (Symbicort)

• fluticasone + salmeterol (Advair)

• mometasone + formoterol (Dulera)

What do LAMA meds result in for asthma and COPD?

anticholinergic (the killer B’s)

• decreeasd bronchorrhea (mucus production)

• decreased bronchoconstriction

Example of LAMA meds used for asthma and COPD?

• tiotropium (Spiriva)

  • inhaler

What does management of LAMA’s for asthma and COPD involve?

trial & error

What controller med may be more efficacious than the other for COPD?

LAMA may be more efficacious than LABA

What results from methylxanthines in COPD and asthma?

• bronchodilation via smooth muscle relaxation

What is example of methylxanthine med used for asthma and COPD?

• theophylline (Theo-dur, Uniphyl)

What is important regarding managing/observing PT on methylxanthines?

narrow therapeutic window, can check serum levels via blood test

What controller med for COPD and asthma has high potential for drug interactions?

methylxanthines

What side effects have a high incidence for PT on methylxanthines?

CV, GI, and CNS effects

What controller med is used as a last resort for COPD and asthma?

methylxanthine

What is the primary rescue med for asthma and COPD?

SABA

What do SABAs do for asthma and COPD?

• relax bronchial smooth muscle

What is SABA the drug of choice for regarding prevention?

exercise-induced bronchospasm

How far before exercise should SABA be taken?

15-30 minutes

What is example of SABA med for asthma and COPD?

• albuterol (Proventil, Ventolin)

What should all PT with asthma or COPD be prescribed and have readily available?

a SABA

What is the primary limiting factor of inhaled SABA meds?

tachycardia

What is the function of a spacer?

improves efficacy of inhaler medications

What is SABA specifically the drug of choice for?

treatment of a persistent cough in PT with uncomplicated acute bronchitis

What are potential adverse effects of nebulized SABA meds in asthma and COPD?

• increased HR

• rapid a-fib

• pharyngitis

• tremors

What treatment often improves tachycardia?

nebulized SABA

What are some types of nebulizers?

• home nebulizer

• hospital nebulizer

• equine nebulizer

• canine nebulizer

• feline nebulizer

• guinea pig nebulizer

• bunny nebulizer

What do SAMAs do for asthma and COPD PT?

• inhaled anticholinergics

• decrease bronchoconstriction

• decrease bronchorrhea (mucus production)

What are examples of SAMAs for asthma and COPD?

• ipratropium (Atrovent)

• ipratropium + albuterol (DuoNeb, Combivent, Combineb)

What are systemic corticosteriods?

anti-inflammatory medications primarily used as a rescue med for asthma and COPD

When are systemic corticosteroids used as controller meds?

for “severe persistent asthma,” but generally avoided as controller therapy for COPD

What are examples of commonly used preparations of systemic corticosteroids

• oral prednisone

• oral prednisolone liquid

• IV methylprednisolone (Medrol, Solumedol)

What are reasons why steroid use is discouraged as controller therapy for obstructive lung diseases, specifically COPD?

• significant immunosuppressive effects

• may exacerbate CHF

• may lead to or exacerbate hypertension, hyperglycemia, cataract formation, myopathy, osteoporosis, and psychoses

• adrenal insufficiency may occur following rapid withdrawal

What does asthma classification determine?

optimum controlled therapy by classifying the underlying asthma into categories

What are the categories for asthma classification?

• frequency of:

  • symptoms during the day

  • night-time awakenings

  • SABA (rescue inhaler) use

  • exacerbations requiring oral steriods

  • intereference with ADLs

• pulmonary function studies (PFTs)

What are pulmonary function studies (PFTs)?

objective tests that quantify the degree of obstruction

Intermittent asthma treatment

• SABA

• no daily controller meds

Mild persistent asthma treatment

• SABA

• daily low-dose inhaled corticosteroid

  • fluticasone

  • budesonide

  • beclomethasone

Moderate persistent asthma treatment

• SABA

• daily low-dose inhaled steriod + inhaled LABA

  • budesonide + formoterdol

  • fluticasone + salmeterol

  • mometasone + formoterol

Severe persistent asthma treatment

• SABA

• high-dose ICS + LABA

• consider oral prednisone

What is the staging system for COPD?

GOLD classification system (stages A-D)

Global initiative for Obstructive Lung Disease

What are tests and findings done to determine COPD staging?

• spirometric findings (PFTs)

• # of exacerbations in past 12 months

• modified medical research council dyspnea scale questionare (mMRC)

• COPD assessment test questionare (CAT)

What medications should be prescribed for patients in all stages of COPD?

SABA or SAMA

What is allergic rhinitis?

inflammation of the nasal mucous membranes

When do symptoms of allergic rhinitis develop?

following inhalation of an antigen

What type of cells are activated during allergic rhinitis and what do they release?

mast cells

• pro-inflammatory factors

  • histamines

  • leukotrienes

What do PT with allergic rhinitis present with?

• sneezing

• itchy nose

• clear rhinorrhea

• nasal congestion

• nonproductive cough

What are the primary therapies for allergic rhinitis?

• intranasal steroids

• oral antihistamines

Where are allergic rhinitis meds located?

OTC

What are intranasal corticosteroids the drug of choice for?

allergic rhinitis

What are intranasal corticosteroids effective for?

• sneezing

• itching

• rhinorrhea

• nasal congestion

What are the side effects of intranasal corticosteroids?

minimal systemic side effects (that’s where the money is)

How long does it take to see improvement when using intranasl corticosteroids?

up to 2 weeks

What are examples of intranasal corticosteroids?

• fluticasone

• beclomethasone

• budesonide

• mometasone

• triamcinolone

What are oral antihistamines?

H1 antagonists

What do oral antihistamines target?

• sneezing

• rhinorrhea

• itchiness of the eyes and nose

When are oral antihistamines most effective?

when used prophylactically

Why are first generation antihistamines avoided while second generation antihistamines are better tolerated?

first generations can cause excessive sedation

What is an example of a first generation antihistamine?

• diphenylhydramine (Benadryl)

What are examples of brand names for second generation anithistamines?

• Allegra

• Claritin

• Clarinex

• Zyrtec