pulmonary review asthma and copd pharmacology...
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Pulmonary Review
asthma and copd
pharmacology review
APRN Pharmacology conference
Jason Kjono PA-C
Asthma
• Statistics
– 22 million Americans have asthma
– Most common disease of childhood
– 6 million children
– Economic impact 5.1 to 8 billion/yr
Asthma
• Definition
– Chronic inflammatory disorder of the airways in which
many cells and cellular elements play a role: in
particular, mast cells, eosinophils, neutrophils, t
lymphocytes, marcophages, and epithelial cells. In
susceptible individuals, this inflammation cause
recurrent episodes of coughing, wheezing
breathlessness and chest tightness. These episodes
are usually associated with widespread but variable
airflow obstruction that is often reversible either
spontaneously or with treatment.
Asthma
• Bronchoconstriction– Smooth muscle constriction that quickly narrow the
airway in response to exposure to a variety of stimuli including allergens or irritants
• Airway hype responsiveness– An exaggerated bronchoconstriction response to
stimuli
• Airway edema– As disease becomes more persistent and
inflammation becomes more progressive, edema, mucus hyper secretion, and formation of inspissated mucus plus further limit airflow
Asthma
• Long standing untreated asthma leads to
– Remodeling of airways
– Incomplete reversibility
– Sub-basement fibrosis
– Mucous hyper secretion
– Injury to epithelial cells
– Smooth muscle hypertrophy
– angiogenesis
Asthma
• Causes
– Innate immunity
– Genetics
– Environmental factors
• Airborne allergens
• Viral URI’s
• Tobacco smoke
• Pollution
• Diet
Asthma
• Diagnosis– Detailed medical history
– Spirometry
– Methacholine challenge
– Complete Pulmonary functions (LV,DLCO)
– CXR – look for chronic hyperinflation
– Biochemical markers• Cbc, ige sputum, allergy testing
– Physical exam• Upper respiratory system
• Chest
• Skin
Asthma
• Symptoms– Dyspnea
– Wheezing
– Cough (worse at night)
– Chest tightness
– Sputum production
– Worsening symptoms with• Exercise
• Viral infection
• Inhaled allergens (pets, dust mites)
• Irritants (tobacco, airborne chemicals)
• Changes in weather
• Emotional distress
• Stress
• Menstrual cycle
Asthma
• Pathophysiology
– Variable and recurring symptoms
– Airway obstruction
– Bronchial hyperresponseiveness
– Airway inflammation
Spirometry
• Pre and post bronchodilator
– Obstructive pattern
– Standardized prediction for age race gender ht wt
• Decreased FEV1– FEV1 >80%, FEV1/FVC >85% - intermittent
– FEV1 >80%, FEV1/FVC >80% - mild
– FEV1 60 – 80%, FEV1/FVC 75% - 80% mod
– FEV1 <60%, FEV1/FVC <75% - severe
– Bronchodilator response
– >12% increase
Methocholine (MCT)
• MCT
– Diagnostic for bronchial hypperreactivity
• PDF drops > than 20% on level 1 thru 5
Asthma
• FIGURE 3. SUGGESTED ITEMS FOR MEDICAL HISTORY*
• 1. Symptoms
• Cough
• Wheezing
• Shortness of breath
• Chest tightness
• Sputum production
• 2. Pattern of symptoms
• Perennial, seasonal, or both
• Continual, episodic, or both
• Onset, duration, frequency (number of days or nights,
• per week or month)
• Diurnal variations, especially nocturnal and on awakening
• in early morning
• 3. Precipitating and/or aggravating factors
• Viral respiratory infections
• Environmental allergens, indoor (e.g., mold, house-dust
• mite, cockroach, animal dander or secretory products)
• and outdoor (e.g., pollen)
• Characteristics of home including age, location, cooling and
• heating system, wood-burning stove, humidifier, carpeting
• over concrete, presence of molds or mildew, presense of
• pets with fur or hair, characteristics of rooms where
• patient spends time (e.g., bedroom and living room with
• attention to bedding, floor covering, stuffed furniture)
• Smoking (patient and others in home or daycare)
• Exercise
• Occupational chemicals or allergens
• Environmental change (e.g., moving to new home; going on
• vacation; and/or alterations in workplace, work processes,
• or materials used)
• Irritants (e.g., tobacco smoke, strong odors, air pollutants,
• occupational chemicals, dusts and particulates, vapors,
• gases, and aerosols)
• Emotions (e.g., fear, anger, frustration, hard crying or laughing)
• Stress (e.g., fear, anger, frustration)
• Drugs (e.g., aspirin; and other nonsteroidal anti-inflammatory
• drugs, beta-blockers including eye drops, others)
• Food, food additives, and preservatives (e.g., sulfites)
• Changes in weather, exposure to cold air
• Endocrine factors (e.g., menses, pregnancy, thyroid disease)
• Comorbid conditions (e.g. sinusitis, rhinitis, gastroesophageal
• reflux disease (GERD)
• 4. Development of disease and treatment
Asthma
Asthma
• Elements of care
– Education
– Environmental Control
– Medications
– Assessment and monitoring
• Severity
• Control – peak flows
Asthma
• Associated diagnosis
– Sinusitis
– Pharnygitis
– Execma
– Allergies
– Endocrine abnormalities
Asthma
• Treatment
• NIH guidelines
– Step up
– Step down
• Lowest possible dose for effectiveness
• Vaccinations
– Pneumococcal
– influenza
Asthma
Pulmonary Meds
• Corticosteroids (ICS)
• Cromolyn
• Immunomodulators
• Leukotriene modifiers (LTRAs)
• Long Acting Bronchodialotrs(LABA)
• Methyxanthines
• Anticholingerics
• Short acting bronchodilators (SABA)
• Systemic Corticosteroids
Short Acting beta agonist
• Class – Beta 2 Agonist
• Purpose – Bronchodilators thru smooth muscle relaxation
• Maintenance and rescue – daily scheduled, prn
• Effectiveness – quick acting bronchodilator –relief in minutes up to 4-6 hours per dose
• Length - lifetime
• Dosing – 2 to 4 puffs qid and prn
• Side effects - tachycardia
• Forms – HFA, neb solution, liquid, tablets
Beta 2 Agonist
• Albuterol (proair, ventolin, proventil etc)
– 2 to 4 puff or neb QID and PRN
– HFA – 90 mcg/ puff
– Neb – 0.042% or 0.083% in 3ml vial
• 0.5% in 20 ml dropper
– Liquid – 2mg/5ml
– Tablet – immediate release 2 to 4mg tabs
• Extended release – 4 to 8 mg
Beta 2 Agonist
• Xopenex (levalbuterol)
– HFA – 45mcg/puff
– Neb – 0.31mcg, 0.63mcg, 1.25mcg /3ml
– Usually reduces tachycardia side effects
caution in those on MAOI’s
Systemic Corticosteroids
• Class - Corticosteroids
• Purpose – Anti-inflammatory
• Maintenance in severe disease, exacerbation relief
• Length- Burst and taper, chronic
• Dosing- single dose to chronic
• Side effects – Weight gain, emotional liability, water retention, adrenal suppression, cataracts, diabetes, immunosupression
• Forms- Oral, IM, IV
• Prednisone and Medrol
Corticosteroids
• Flovent
• Pulmicort
• Asmanex
• Qvar
• Aerobid
ICS
• Class – anti-inflammatory
• Purpose – reduce airway hyperresponsiveness, inhibit cell migration and activation, and block late phase reaction to allergens (reduce inflammation in bronchial tubes)
• Maintenance therapy – not indicated for acute asthma exacerbations
• Effectiveness – most consistent long term control – reduces impairment and risk of exacerbations
• Length – Long term use at varying doses
• Dosing – lowest effective dose – step up and step down therapy
• Side Effects – Thrush, pneumonia, pharyngitis cough, immunosuppressant, adrenal suppression
• Forms – HFA, Diskus, flexhaler, twisthaler, combo with LABA
• Spacer – recommended for HFA
ICS
• Pulmoicort (Budesonide)– Nebulizer 0.25mg/2ml, 0.5mg/2ml
– Flexihaler 90 mcg, 180 mcg• 1 to 2 puffs bid
• Flovent (fluticasone)– HFA - 44mcg, 110 mcg, 220mcg,
• 2 puffs up to BID
– Diskus– 50mcg, 100 mcg, 250 mcg• 1 puff up to BID
ICS
• Asmanex (Mometasone)
– Twisthaler 110 mcg, 220 mcg
• 1 to 2 puffs bid
• Qvar (Beclomethasone)
– HFA – 40mcg, 80 mcg
• 40 mcg – 1 to 4 puffs bid
• 80 mcg – 1 to 2 puffs bid
LABA
• Class – long acting beta 2 agonist
• Purpose – Direct bronchodilators 12 hour effectiveness
• Manteca therapy- not to be used as monotherapy is asthma
• Effectiveness – highly effect with combo of ICS
• Length – long term
• Dosing – single dose bid
• Side effects- Tachycardia, cough
• Forms – Diskus, Inhalation pill form, combo with ICS, nebulizer
• Precautions – rinse and spit
LABA
• Serevent (Salmeterol)
– Diskus – 50 mcg
– 1 puff bid
• Foradil (Formoterol)
– Pill puncture – 12mcg
– 1 puff bid
LABA
• Perforomist (formoterol)
– Neb – 20 mcg/ 2ml
– 1 neb bid
• Brovana (arformoterol)
– Neb – 15 mcg/2ml
– 1 neb bid
Combo ICS and LABA
• Advair (fluticasone/salmeterol)– Diskus
• 100/50 mcg – 1 puff bid
• 250/50 mcg – 1 puff bid – indicated for copd
• 500/50 mcg – 1 puff bid
– HFA • 45/21 mcg – 2 puffs bid
• 115/21 mcg – 2 puffs bid – dose indicated for copd
• 230/21 mcg – 2 puff bid
• Symbicort (budesonide/formoterol)– HFA
• 80/4.5 mcg – 2 puffs bid
• 160/4.5 mcg – 2 puffs bid (COPD)
• Dulera (mometasone/formoterol)– HFA
• 100/5 mcg – 2 puffs bid
• 200/5 mcg – 2 puffs bid (COPD)
Immunomodulators
• Class – Leukotreine Modifiers – Interfer leukotreine’s which are released by mast cells,
eosinophils and basophils in the allergic cascade
• Purpose – Asthma and Allergies
• Anti IGE- monoclonal antibody that prevents binding of IGE
• Maintenance
• Effectiveness – low to high pending individual response
• Length – Short and long term
• Dosing – Depends on age
• Side effects – Nausea, liver dysfunction
• Forms - Oral tablet
Leukotriene Modifiers
• Singulair (Monrelukast)– Asthma and Allergic rhinitis
– Tablet 10mg, 20mg - > 14 yo
– Chewable Tabs – 5mg – 6-14
– Oral Granules – 4 mg - 12mth-23 mths asthma, 6-23mths allergic rhinits, 2-5 athma and allergic rhinitis
– Daily dosing
• Zyflo (Zileuton)– Chronic asthma
– Tablet 600mg - 1 tab QID
– Monitor LFTs
Anti IGE
• Zolair (Omalizumab)
– Severe Asthma, Allergies
– Treat abnormally high IGE or Severe
symptomolgy
– IM injection every 2 to 4 weeks
– High risk for anaphylaxis – pt must have a epi
pen present , pt can have severe allergic
reaction any time during treatment
Anticholinergics
• Class - Anticholinergics
• Purpose – Inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of airway – indirect bronchodilator– Asthma esp. EIA, COPD
• Maintenance and Rescue
• Effectiveness - High
• Length – Prn, short and long term
• Dosing – set dosing and combo
• Side effects- cough, urine retention, dry mouth, blurred vision
• Forms – HFA, neb, combo
Anticholinergics
• Atrovent (ipatropium bromide)– HFA – 2 puffs QID up to 12 PUFF QD
– Neb – 500mcg TID to QID
• Combivent (ipatropium bromide/albuterol– Combo
– HFA – 2 puffs QID up to 12 PUFF QD
– Neb – 2.5mg alb/0.5mg per 3ml vial
• Spriva (tiotropium)– Pill inhalation device
– Once day doing
– 18mcg per dose
– Has been shown to decrease pneumonia in copd
Methylxanthines
• Class - Methylxanthines
• Purpose – mild to moderate bronchodilator with
mild anti-inflammatory effects
• Adjunct therapy
• Length – long term with toxicity monitoring
• Dosing – daily with ER and bid
• Side effects – Toxicity, irritability, nausea, palp,
tachycardia
• Forms- tablets
Methylxanthines
• Theophylline (Uniphyl, Theo 24, TheoDur)
– Adults – 5-13mg/kg/d in divided doses
– Monitor for toxicity
Alternatives
• Cromolyn
– Stabilizes mast cells and interfere with
chloride channel functions
– Alternative therapy not proffered
– Inhaled – 2 puffs QID
– 1.75mg/actuation
– Side effects – dysphonia, bad taste
OTC
• Oral Antihistamines
• Primatene Mist
• Mucinex
ER Treatment (NIH)
ER Treatment (NIH)
COPD
• Chronic Obstructive Pulmonary Disease
– Definition – Preventable and treatable disease
– Airflow limitation that is not fully reversible
– Usually progressive
– Abnormal inflammatory response of the lungs
to noxious particles or gases
COPD
• Symptoms
– Cough
– Sputum production
– Dyspnea on exertion
COPD
• Risk Factors
– Smoking
– Occupational dust and chemicals
– Indoor air pollutions
– Outdoor air pollution
– Genetic Factors – alpha 1 antitrysian
COPD
• Diagnosing
– Chronic cough
– Chronic sputum production
– History of exposure
– Dyspnea –
• progressively worsening
• Worse with exercise
• Persistent
COPD
• Spirometry – FEV1 – post bronchodilators
• decreased
– FVC
– FEV1/FVC• Decreased
• Lung Volumes – RV (residual Volume)
• Usually increased– hyperinflation
DLCO– Normal
– Decreases usually associate with emphysema
COPD
• CXR– Hyperinflation
– Lung cancer screening
• RNE– Quick exercise testing for hypoxia
• 6 MIN WALK– Formal exercise testing
• ABG– Respiratory failure
• APHA-1 ANTITRYSIN– Genetic copd
COPD
• GOLD Staging by spirometry– Stage 1
• Mild– FEV1 > 80 %
– FEV1/FVC <70%
– Stage 2• Moderate
– FEV1 < 80%
– FEV1/FVC <70%
– Stage 3• Severe
– FEV1 <50%
– FEV1/FVC < 70%
– Stage 4• Very Severe
– FEV1 <30%
– FEV1/FVC < 70%
COPD
• Treatment– Reduce risk factors
• Smoking cessation– Chantix
– wellbutrin
• education
– Pharmacologic
– Exercise• Pulmonary rehab
– Diet
– Vaccines • Influenza
• pneumococcal
COPD
– Surgical
– Antibiotics
– Corticosteroids
• Manage exacerbations
– Mucolytic
– Antitussives
– Oxygen
• Oxygen <88%
• Titrate for effect
COPD
• Therapy (GOLD standards)– As staging increase add previous stage treatment
– Stage1• Short acting bronchodilators
– Stage2• Long acting bronchodilators
• Pulmonary rehab
– Stage 3 • ICS
– Stage 4• Long term oxygen
• Surgical
• Oral corticosteroids
References
• Global Initiative for Chronic Obstructive
lung disease
• Guidelines for the diagnosis management
of asthma
• NIH asthma Guidelines
• Questions?????
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