31 - Respiratory System

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1 31 - Respiratory System Asthma 1. Asthma has two components. Name the two components. 2. What are the common triggers of asthma? (LP p319) (e.g., pets) Upper respiratory infections ( ) 3. Describe a normal lung vs. an asthmatic lung. (LP p320) Normal Lung - Smooth muscle in wall is - Airway Asthmatic Lung - Smooth muscle in wall is - Mucus and inside airway 4. What are the two components of an asthma attack? (LP p320) 5. What are the frontline medications for treatment of asthma? 6. Which type medication do you use for inflammation and which type do you use for bronchoconstriction? (LP p ) Corticosteroids 2 -adrenergic agonists - 7. How is asthma diagnosed? Asthma is a 8. When you hear asthma what should you think? 9. Name some other symptoms of asthma besides cough. (LP p320) Chest (SOB) Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-1

2 10. What tool can help confirm the diagnosis of asthma? (pulmonary function test- PFT) 11. What are the goals of asthma treatment? (LP p320) Reduce - Same quality of life as non-asthmatic patient - Reduce chronic symptoms - Reduce use of rescue medications - Keep their normal activities Reduce 12. Asthma is not a disease, but a disease. Classification 13. What are the classifications of asthma? (LP p321) Symptoms Nighttime Symptoms Mild intermittent 2/month persistent > 1/week, but <1/daily >2/month persistent Daily >1/week Result Of Peak Flow Or Spirometry 80% predicted function, with <20% variability 80% predicted function, with 20-30% variability 60-80% predicted, with >30% variability <60% predicted, with >30% variability Long-Term Control No daily inhaled corticosteroids Increase dose inhaled corticosteroids + β 2 agonist inhaled corticosteroids + Long-acting β 2 agonist (LP p321; Yawn, BP (September 2008). "Factors accounting for asthma variability: achieving optimal symptom control for individual patients". Primary Care Respiratory Journal ) persistent Daily Frequent Rescue Relief available Short-acting β 2 agonist 14. All asthmatics need what type of medication? (LP p321) Short-acting 15. How do 2 agonists work? (LP p321) As 16. Short-acting medications typically last for how long? (LP p321) onset 17. Name some common examples of long-acting 2 agonists. (LP p322), formoterol Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-2

3 18. Why are these medications considered long-acting? (LP p322) Have a component Binds to the cell membrane into the airway Lasts hours 19. What type of patients would need to be on a daily long-acting 2 agonist? Use inhaler on a daily basis Classified as moderate or 20. What is important to know about the side effects of long-acting 2 agonists? (LP p ) differences between people in the response to 2 agonists Site on the receptor in the lung who are homozygous for Increase risk for when starting on a long-acting 2 agonist 21. What percent of the population represents this side effect described above? 22. Inflammatory component to asthma is largely related to release. 23. Corticosteroids can have an indirect effect on what component of asthma? 24. What are the routes of administration for corticosteroids? (LP p ), systemic/oral or IV 25. When you think of inhaled corticosteroids you should think of them as a medicine. 26. All patients who have an asthma classification of what should be on inhaled corticosteroids? (LP p322) persistent Moderate persistent persistent 27. Patients who are already on daily medications of inhaled corticosteroid and are having an acute exacerbation of their asthma will probably need to be put on what route of medication? (LP p323) steroid medication Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-3

4 28. If a patient is using an inhaler they also need to use what? (LP p323) 29. What is one important side effect of corticosteroids? (oral thrush) Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-4

5 Quick Review 1 1. What are the two components of an asthma attack? (LP p320) 2. How is asthma diagnosed? with respiratory symptoms: cough (worse at night), recurrent wheeze, recurrent difficulty breathing with exercise, recurrent chest tightness Asthma is airway obstruction (variable expiratory outflow obstruction) 3. What is the most common symptom of asthma? 4. What tool can help confirm the diagnosis of asthma? (pulmonary function test) 5. What are the goals of asthma treatment? (LP p 320) Reducing Reducing 6. What are the two main drug categories used to treat the main components of asthma? (LP p ) Bronchoconstriction: agonist Inflammation: Classification 7. What are the classifications of asthma, and how is asthma treated based on this classification system? (LP p321) Symptoms Nighttime Symptoms Mild intermittent 2/month persistent > 1/week, but <1/daily >2/month persistent Daily >1/week Result Of Peak Flow Or Spirometry 80% predicted function, with <20% variability 80% predicted function, with 20-30% variability 60-80% predicted, with >30% variability <60% predicted, with >30% variability Long-Term Control No daily inhaled corticosteroids Increase dose inhaled corticosteroids + β 2 agonist inhaled corticosteroids + Long-acting β 2 agonist (LP p321; Yawn, BP (September 2008). "Factors accounting for asthma variability: achieving optimal symptom control for individual patients". Primary Care Respiratory Journal ) persistent Daily Frequent Rescue Relief available Short-acting β 2 agonist Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-5

6 8. Complete and study the following tables of 1 st line asthma therapy. (LP p ) Adrenergic Agonists Action Therapeutic Use Adverse Effect Β 2 AGONISTS Albuterol- Pirbuterol Terbutaline- given Levalbuterol- stereoisomer of Selective β 2 receptors, they are bronchodilators Potent that relax airway smooth muscle **all asthmatics should be prescribed a quick-relief inhaler LONG-ACTING Β 2 AGONISTS Salmeterol Formoterol Selective β 2 agonist Stimulate β 2 receptors Potent bronchodilator that relax airway smooth muscle (also used in anaphylaxis, open angle glaucoma, hypotension) Not for attacks Bronchodilation X 12 hours (but slower onset of action) Use as adjunct to inhaled corticosteroid for asthma control, hyperglycemia, hypokalemia, hypomagnesemia (minimized with inhalation route) Same as above Corticosteroids Action Therapeutic Use Adverse Effect INHALED CORTICOSTEROIDS Triamcinolone Budesonide Fluticasone Decrease cascade Inhibit phospholipase DOC in asthma Minimal side effects (oral thrush) ORAL/SYSTEMIC Prednisone Prednisolone Triamcinolone Methylprednisolone Decrease inflammatory cascade Inhibit phospholipase A2 Severe exacerbation of asthma (status asthmaticus), hyperglycemia, osteoporosis, Cushing syndrome, weight gain, exacerbate diabetes,, acne, cataracts -dependent upon dose and term of tx 9. What are the side-effects of the beta-2-agonists? (LP p321) Hypokalemia Hyperglycemia Hypomagnesemia 10. Why should spacers be used when inhaling steroids? (LP p323) Reduce incidence of Help smaller particles enter terminal airways Better penetration Reduce Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-6

7 11. How long does it take for a systemic steroid to begin reducing inflammation? Which works more rapidly, oral or intravenous steroid? hours No ; both take 4 hours 12. There are combination products that include inhaled corticosteroids and long-acting β 2 agonists: Budesonide + formoterol ( ) Fluticasone + salmeterol ( ) Alternative Asthma Drugs 1. What are the 3 leukotriene antagonists? (LP p324) Montelukast Zafirlukast 2. What is the most common leukotriene antagonist that you will see in practice? (Singulair) 3. What is the mechanism of action for montelukast and zafirlukast? (LP p324) Block receptors 4. What is the mechanism of action for zileuton? (LP p324) Block leukotriene 5. What are the adverse effects of leukotriene antagonists? (LP p324) Eosinophilic (Churg-Strauss syndrome) 6. Which leukotriene antagonists inhibit cytochrome P450? (LP p324) 7. Cromolyn is used to block the bronchoconstriction caused by asthma and induced asthma. 8. Cromolyn has to be dosed how many times a day? Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-7

8 9. Which classifications of drugs are commonly used for asthmatics in the hospital?, the classic medication being ipratropium 10. Cholinergic antagonists are used in conjunction with what other type of medications for asthmatics in an acute exacerbation? 11. What is the challenge for using theophylline? (LP p325) Narrow window 12. How does omalizumab work? (LP p325) Monoclonal antibody that binds Prevents response Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-8

9 Quick Review 2 1. Complete and study the following table of alternate asthma therapy. (LP p ) 2 ASTHMA DRUGS ACTION THERAPEUTIC USE ADVERSE EFFECT Improve asthma control Not medications LEUKOTRIENE ANTAGONISTS Zileuton Zafirlukast Montelukast (Singulair) MAST CELL STABILIZER Nedocromil CHOLINERGIC ANTAGONISTS Ipratropium (Atrovent) Inhibits (blocks conversion of arachidonic acid to leukotrienes) Block receptors Stabilize cells Prevent of mast cells; mast cells generate histamine Block mediated contraction of airway smooth muscle and mucus secretion Allergic rhinitis asthma Not medications, more preventative Asthma (not acute attack) Allergic rhinitis medication with albuterol patients Patients unable to tolerate adrenergic agonists Elevation in enzymes, (Churg-Strauss syndrome) Rare, throat irritation Rare (slow onset) METHYLXANTHINE Theophylline RECOMBINANT MONOCLONAL ANTIBODY Omalizumab (Xolair) Recombinant DNA-derived monoclonal antibody binds decrease release of allergic response mediators 3 rd or 4 th line drugs - allergic asthma Not commonly used, $$$, dosage limitations (inj) 2. What medications are used in the treatment of acute asthma exacerbation?, commonly methylprednisolone or prednisone of albuterol + ipratropium (A + A Neb) More albuterol O 2 as needed Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-9

10 Chronic Obstructive Pulmonary Disease (COPD) 1. What is COPD? (LP p325) Chronic obstructive pulmonary disease COPD is 2. COPD treatment is focused on what? symptoms and of COPD 3. When you hear COPD what should you think? 4. Classification of COPD is divided into what 3 categories? (LP p326) Mild COPD COPD Severe COPD 5. How do you treat mild COPD? (LP p326) ( 2 agonist) Daily dose of antagonist (ipratropium) 6. What is one difference in the treatment between moderate and severe COPD? (LP p326, Fig 27.7) Patients will often need therapy and therapy during exacerbation Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-10

11 Quick Review 3 1. What is COPD? (LP p325) Chronic obstructive pulmonary disease Two main categories of COPD: - - is the greatest risk factor 2. How does the stage of COPD determine the treatment? (LP p326) Stage Smoker Treatment ; influenza vaccine 1 Mild (FEV1 > 80%, but FEV1/FVC < 70%) bronchodilator, as needed 2 Moderate (FEV %) Everything above bronchodilator 3 Severe (FEV %) Everything above Inhaled If nothing is working use theophylline Long-term therapy Acute exacerbation (increased volume and purulence of secretions) Antibiotics steroids Oxygen therapy 3. What is the general rule for when a COPD patient requires home oxygen? When pulse oxygen is 4. Complete and study the following table of drugs used to treat COPD. (LP p ) COPD Drugs Action Therapeutic Use Adverse Effects INHALED ANTICHOLINERGICS (Atrovent) Tiotropium (Spiriva) Block mediated contraction of airway smooth muscle Patients unable to tolerate adrenergic agonists COPD + asthma Rare (slow onset) β 2 AGONISTS Albuterol (short-acting) (longacting) Selective β 2 agonist Potent bronchodilator that relax airway smooth muscle quick relief of symptoms Tachycardia, hyperglycemia, hypokalemia, hypomagnesemia (minimized with inhalation route) Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-11

12 5. What are the side-effects of theophylline overdose? What is the drug of choice for treatment? (LP p325) Treat with, like propranolol Treat with, like diazepam or lorazepam Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-12

13 Allergic Rhinitis 1. What are the most common symptoms of allergic rhinitis? (LP p326) Runny or congested nose Itchy nose 2. What is the first-line treatment for allergic rhinitis? (LP p326) (H 1 -receptor blocker) 3. List some examples of first generation antihistamines. (Benadryl), chlorpheniramine 4. What are some of the systemic side effects of first generation antihistamines? (LP p326) Sleepiness Decreased urination 5. List some examples of second generation antihistamines. (Claritin), (Allegra) 6. Alpha-adrenergic agents are typically described as. 7. How do -adrenergic agonists work? (LP p327) Cause Decrease in the nasal passages 8. Patients who use -adrenergic agonists as a nasal spray need to be warned about what? (LP p327) If used for longer than 2-3 days they can experience when stopped 9. What other medications can be used for allergic rhinitis to decrease inflammation? nasal sprays (intranasal corticosteroids) 10. What are the most common side effects from inhaled nasal spray corticosteroid? (LP p327) Nasal Nose bleeds in their mouth Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-13

14 11. Name some other treatments for allergic rhinitis that you should be aware of. antagonists and sprays Cough 12. What are some common causes for cough? Cold viruses Pneumonia Influenza (GERD) 13. What is the gold standard cough medication? (LP p327) 14. What is the mechanism of action of codeine? (LP p327) the sensitivity in the cough center in the 15. List some significant side effects of codeine. (LP p327) Sleepiness Constipation to codeine 16. Name another good choice for the treatment of cough that is over-the-counter. (LP p327) 17. You will often see dextromethorphan paired with what? Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-14

15 Quick Review 4 1. Complete and study the following table of drugs used to treat allergic rhinitis. (LP p326) Allergic Rhinitis Drugs Action Therapeutic Use Adverse Effects ANTIHISTAMINES 1st Gen Diphenhydramine (Benadryl) Chlorpheniramine Brompheniramine Clemastine Reversible inhibition of receptors Allergy Nausea and vomiting ANTIHISTAMINES 2nd Gen Loratadine (Claritin) Desloratadine (Clarinex) Fexofenadine (Allegra) Cetirizine (Zyrtec) α-adrenergic AGONISTS - Intranasal Phenylephrine Oxymetazoline (Afrin) Reversible inhibition of receptors Constrict dilated in nasal passageways; cause Allergy Short-term nasal congestion Nose bleeds (epistaxis) Antimuscarinic (anticholinergic) side effects Less than 1 st generation Aerosol- more rapid onset and fewer side effects α-adrenergic AGONISTS - Systemic Pseudoephedrine Phenylephrine INTRANASAL CORTICOSTEROIDS Beclomethasone Budesonide Fluticasone Flunisolide Triamcinolone MAST CELL STABILIZERS Cromolyn (intranasal) Constrict dilated arterioles in nasal passageways; cause vasoconstriction Decrease swelling of nasal mucosa to improve airflow Prevent release of mast cell mediators Short-term nasal congestion Relieve symptoms of allergic and non-allergic rhinitis Optimum effect if 1-2 weeks prior to allergen exposure (also asthma prophylaxis) raise, dizziness, palpitations nasal (nose bleeds) Rare Bitter taste, throat irritation 2. Why should intranasal alpha-adrenergic agonists not be used long-term? (LP p327) Risk of 3. Which patient populations in particular should use caution when taking systemic alpha-adrenergic agonists? patients 4. Why should first generation antihistamines not be used in the elderly? Anticholinergic side effects Mad as a hatter - Causes in elderly patients Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-15

16 5. What should be used to relieve nasal secretions in infants? Saline drops and 6. What are some of the most common causes of cough? Postnasal drip from allergic rhinitis Asthma Pneumonia Smoking 7. Complete and study the table of drugs used to treat cough. (LP p327) Drug Action Therapeutic Use Adverse Effects ANTITUSSIVES Non-narcotics Carbetapentane Dextromethorphan(drug-DM) suppresses cough center synthetic morphine derivative Fewer side effects ANTITUSSIVES Narcotics Codeine (drug-ac) Hydrocodone suppresses medullary cough center *codeine is gold standard* Constipation, (myosis), fatigue, MUCOLYTICS Guaifenesin MUCOLYTICS N-acetylcysteine (Mucomyst) Loosens ; expectorate sputum; increases Mucolytic (loosens mucus plugs) sputum production, loosens mucous, does not cough reflex patients with mucus Loosen mucus plugs (antidote to acetaminophen OD) Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-16

17 End of Session Quiz Respiratory System 1. Fill in the blanks in the table below about which agents are used for long-term control of asthma. (LP p321) Classification of Severity of Asthma Mild intermittent Daily Therapeutic Agent(s) of Choice Mild persistent Moderate persistent Severe persistent 2. What are the side effects for the following medications? (LP p ) Montelukast Cromolyn Diphenhydramine Albuterol 3. What medication would you use to treat the following patients? (LP p ) A 9 year old girl with mild intermittent asthma needs quick relief A 72 year old man with COPD needs a daily controller medication A 34 year old woman with severe persistent asthma is having side effects to her corticosteroids and needs an adjunct therapy to help reduce her dose A 28 year old man has a bad cough associated with an upper respiratory infection Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-17

18 4. Match the agents below with the respiratory condition they are used to treat. More than one answer may be correct. (LP p ) a. asthma b. allergic rhinitis c. COPD d. cough opiates cromolyn β 2 -adrenergic agents antihistamines ipratropium α-adrenergic agents theophylline zafirlukast corticosteroids omalizumab 5. What is the mechanism of action of the following medications? Cromolyn Ipratropium Salmeterol Terbutaline Guaifenesin Desloratadine Tiotropium Prednisone 6. What are the side effects of theophylline overdose? (LP p325) Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-18

19 7. What medications are used to treat moderate COPD? (LP p ) 8. What inhaled mucolytic is often used in cystic fibrosis patients? 9. What are the side-effects of the β 2 agonists? 10. Which β 2 agonist is least likely to cause tachycardia? Solid Pharmacology Copyright 2010, Doctors In Training.com LLC, All Rights Reserved 31-19

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