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82 Questions

What is the brand name for albuterol

Proair HFA

What does the upper respiratory tract consist of?

nasal cavity, larynx and pharynx

what does the lower respiratory tract consist of

trachea , bronchi and lungs

What structures make up the alveoli

cilia, cartilage and smooth muscle

In the alveoli, which structures/components are NOT present?

epithelial lining

The aortic and chemoreceptors are activated when?

Ph decreases , Oxygen decreases and CO2 increases

Inflammatory changes in the airways are accompanied by

Vasodilation Edema

Inflammatory changes in the airways are accompanied by

Vasodilation edema recruitment of mast cells eosinophils Th2 lymphocytes Over production of mucous Fibrosis of airway walls

The recruitment mediators of the inflammation changes in the airways include?

IL-3, IL-4, IL-5, and IL-13

Asthma is the syndrome in which there is irreversible , non recurrent obstruction of the airways n response to stimuli

False

Asthma prevalence in the USA in 2021 consist of how many people?

24.96 million

AirDuo Respiclick belongs in which class?

ICS/LABA

Brand names for fluticasone/Salmeterol

Airduo respiclick, Advair Diskus, Advar HFA

How should you use Ellipta?

breathe out away from device , open until you hear a click, close lips tightly to form seal, inhale deep and quickly not covering the vent, wipe mouthpiece

FVC normal predicted range

greater than 80% predicted

FEV1 normal predicted range

greater than 80% predicted

FEV1/FEV normal range for adults

greater than .75 or .80

FEV1/FEV normal range for peds

greater than .85

Which values are important to conisder when evaluating a pt for an obstructive disease?

FEV1 or FEV1/FVC

To determine if the results indicate bronchodilator reversibility what value is important?

% change greater than 12%

This helps patients who have difficulty with inhaler use to ensure delivery of medication to the site of action and can reduce local adverse effects

Spacers

When using a spacer how should you breathe in?

slowly and deeply

When using a spacer device with the inhaler, how would you instruct the patient to take 2 puffs?

Inhale 1 puff at a time. Wait 1 minute in between puffs. and Exacerbations

Yellow Zone range

50-80

Green zone range

80-100

red zone range

anything less than 50

Asthma symptom control consist of

daytime asthma symptoms more than twice a week any night wakenings due to asthma SABA reliever for symptoms more than twice a week any activity limitation due to asthma

Initial treatment for mild to moderate asthma exacerbations include

O2, oral corticosteroids such as dexamethasone , prednisone/prednisolone and High dose SABA

O2 supplemental goal for adults

93%-95%

O2 supplemental goal for children 0-11 years of age

94-98%

Dose for albuterol used in moderate to severe asthma exacerbation initial treatment

4-10 puffs q 20 mins then 6-10 puffs q 1-2 hours

dose for oral corticosteroid prednisone/prednisolone used for initial treatment of moderate-mild asthma exacerbation

40-60mg po daily for 5-7 days for children 3-5 days with 40mg max

dose for oral coricosteroids for dexamethasone used for initial treatment of mild to moderate asthma exacerbation

0.6mg/kg max 16 mg po daily for 1-2 days

What does the clinic or ED/inpatient treatment of asthma exacerbations consist of (hint there are 5 meds to start the patient on)

SABA oxygen IV magnesium sulfate system steroids oral or Iv ipratropium

After an asthma exacerbation attack when should a pt follow up with their pcp provider?

for adults 2-7 days and for children 1-2 days

When a pt has an asthma exacerbation attack and is admitted into the ER what signs should be monitored for improvement?

FEV/FEV1, O2 sat and the symptoms

asthma Exacerbation signs and symtoms for mild-moderate

talks in phrases prefers sitting rather than lying down Accessory muscles not used RR>16 but <30 HR 100-120 O2 sat 90-95% on room air PEF or FEV1 >50% person best or predicted

What are signs and symptoms of severe asthma exacerbation?

Talks in words sits hunched forward accessory muscles used agitated RR>30 HR>120 O2 sat <90% on room air PEF or FEv1 < than or equal of best/predicted

What are the life threatening symptoms of asthma exacerbations

Severe symptoms plus drowsy confused silent chest ( no breath sounds or no air movement)

What position are patients more prone to do during an exacerbationthat lowerers the diaphragm and allows greater lung expansion through gravity

tripoding

What is the dosing regimen for nebulized ipratropium bromide in severe asthma exacerbation?

0.5mg q 20 mins for 3 days then q h for 3 h

Dose for Intravenous magnesium sulfate for severe asthma exacerbations

2 g infused over 20 mins

Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production, and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.

True

What are the causes of COPD

Getomics

Gene(G)-environment(E) interactions occurring over the lifetime(T) of the individual (GETomics) → structural lung damage and/or alter the development/aging processes

What is the FEV1/FVC that is mandatory for COPD diagnosis

less than 0.7 or 70%

When using spirometry what is important to asses for COPD

eosinophils

What is the COPD assessment test called?

CAT

In COPD patients Gold 1 mild is what range for FEV1

greater than or equal to 80% predicted

In COPD patients GOLD 2 moderate range for FEV1 is?

50 to less than 80% predicted

In COPD pts Gold 3 severe range for FEV1?

less that 50% to 30

In COPD pts Gold 4 very severe range for FEV1?

anything less than 30% predicted

What isthe dose for albuterol when it is used as a rescue inhaler?

1-2 puffs q 4-6 hours as needed for asthma

What is the dose for albuterol when used in a asthma exacerbation

90 mcg 4-10 puffs q 20 mins for 3 doses

Brand name for DuoNeb?

Ipratropium Albuterol

Duoneb dosing for mild-moderate COPD exacerbation

100-200 mcg 1 puff q 4-6 h

Albuterol-Ipratropium dosing for severe COPD exacerbation

100-200mcg 1 puff q 1h for 3 doses then 2-4h

Using these antibiotics long term can reduce exacerbations over 1 year

Azithromycin and erythromycin

what is the dosing for azithromycin used to treat moderate or severe exacerbations?

500 mg daily for 3 days or z pack for 5 days

When using antibiotics for moderate exacerbations what should be covered?

Haemophilus influenzae, strep pneumoniae, moraxella catarrhalis

What is the recommended dose for prednisone for COPD exacerbation?

40 mg PO daily for 5 days

What is the frequency dosing for trelegy ellipta

1 inhaler daily (q 24 hours)

What is the frequency dosing for Breztri Aerosphere

2 inhalations BID (q 12 h)

what is the frequency dosing for symbicort

2 inhalations BID (q 12 h)

what is the frequency dosing for breo ellipta

1 inhalation daily (q 24h)

what is the frequency dosing for spiriva handihaler

1 cap daily (q 24 h)

what is the frequency dosing for spiriva respimat

2 inhalations daily (q 24 hours)

what is the frequency for dexamethasone?

q 24 hours for 1-2 days

What qualifys a patient to be well controlled according to the symptoms from the gina box 2-2a

having none of the symptoms

What qualifys a patient to be partly controlled according to the symptoms from the gina box 2-2a

1-2 of the symptoms

What qualifys a patient to be uncontrolled according to the symptoms from the gina box 2-2a

3-4 of the symptoms

What are the 4 symptoms to determine whether a pt is controlled, well controlled or uncontrolled according to the gina box 2-2a

-Daytime asthma symptoms more than twice a week -Night awakenings due to asthma -Using SABA reliever more than twice a week -Activity limitation due to asthma

If the patient has an exacerbation history of having 2 or more moderate exacerbations, or 1 or more that lead to hospitalization what category from the GOLD asssessment tool does this patient belong in.

If a patient has 0 or 1 moderate exacerbations not leading to hospitalization and a mMrc of 0-1 and a CAT test less than 10 what category from the GOLD ABE assessment tool does the patient belong to

If a patient has 0 or 1 moderate exacerbations not leading to hospitalization and a mMrc that is greater than 2 and a CAT test greater than or equal to 10 what category from the GOLD ABE assessment tool does the patient belong to

GOLD initial pharmacological treatment for group E

LABA+ LAMA

GOLD initial pharmacological treatment for Group A

Bronchodiolator

GOLD initial pharmacological treatment for group B

LABA+LAMA

Social determinants of health for asthma

education access and quality health care access and quality neighborhood and built environment economic stability social and community context

Health disparities seen in asthma patients

genetics housing location (urban, near lots of traffic and pollution) socioeconomic status (impact of affording healthcare and meds) Racism (Increased stress, mistrust of healthcare, discriminatory housing practices) Education level and employment opportunities

What is the BB warning for montelukast?

Serious Neuropsychiatric events such as agitation, aggression, depression, sleep disturbances , suicidal thoughts

Discharge managemt for asthma exacerbations include which of the following

SABA, ICS , OCS, MART ( ICS-formoterol prn )

Study Notes

Respiratory Tract

Upper respiratory tract consists of nose, mouth, pharynx, larynx, and trachea
Lower respiratory tract consists of bronchi, bronchioles, and lungs

Alveoli

Alveoli consist of type I and type II alveolar cells, macrophages, and capillaries
Structures/components not present in alveoli include aortic and chemoreceptors

Asthma

Asthma is a syndrome characterized by irreversible, non-recurring obstruction of airways in response to stimuli
Asthma prevalence in the USA in 2021: approximately 25 million people
AirDuo Respiclick belongs to the class of combination inhalers
Brand names for fluticasone/Salmeterol: Advair, Seretide
Ellipta should be used with a steady, deep breath in through the mouth, holding the breath for 3-5 seconds, and then exhaling slowly

Pulmonary Function Tests

FVC normal predicted range: 80-120% of predicted value
FEV1 normal predicted range: 80-120% of predicted value
FEV1/FEV normal range for adults: 0.7-0.8
FEV1/FEV normal range for pediatrics: 0.85-0.95
Important values to consider when evaluating a patient for obstructive disease: FEV1, FEV1/FVC, and FVC
Bronchodilator reversibility: important value is FEV1

Spacer Devices

Spacer devices help patients with difficulty using inhalers to ensure delivery of medication to the site of action and reduce local adverse effects
When using a spacer, breathe in slowly and deeply through the mouth, holding the breath for 3-5 seconds, and then exhaling slowly
To take 2 puffs using a spacer device, breathe out slowly, put the mouthpiece in the mouth, and inhale slowly and deeply through the mouth, holding the breath for 3-5 seconds, and then exhaling slowly; repeat the process for the second puff

Asthma Zones

Yellow Zone range: 50-80% of predicted personal best
Green Zone range: 80-100% of predicted personal best
Red Zone range: <50% of predicted personal best

Asthma Symptoms and Treatment

Asthma symptom control consists of: day and nighttime symptoms, need for rescue medication, and limitation of daily activities
Initial treatment for mild to moderate asthma exacerbations: oxygen therapy, inhaled beta2 agonists, and oral corticosteroids
O2 supplemental goal for adults: maintain O2 saturation >90%
O2 supplemental goal for children (0-11 years): maintain O2 saturation >90%
Dose for albuterol used in moderate to severe asthma exacerbation initial treatment: 2.5-5mg every 20 minutes for 3 doses, then 2.5-5mg every 1-4 hours as needed
Dose for oral corticosteroid prednisone/prednisolone used for initial treatment of mild to moderate asthma exacerbation: 40-50mg/day for 5-7 days
Dose for oral corticosteroids for dexamethasone used for initial treatment of mild to moderate asthma exacerbation: 12-16mg/day for 5-7 days
Clinic or ED/inpatient treatment of asthma exacerbations: oxygen therapy, inhaled beta2 agonists, oral corticosteroids, anticholinergics, and magnesium sulfate

COPD

COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms and airflow obstruction due to abnormalities of the airways and/or alveoli
Causes of COPD: cigarette smoking, air pollution, occupational exposures, and genetic factors
FEV1/FVC mandatory for COPD diagnosis: <0.7
When using spirometry, important to assess for COPD: FEV1, FEV1/FVC, and FVC
COPD assessment test: COPD Assessment Test (CAT)
In COPD patients, GOLD 1 mild: FEV1 ≥80% of predicted value
In COPD patients, GOLD 2 moderate: FEV1 ≥50% and <80% of predicted value
In COPD patients, GOLD 3 severe: FEV1 ≥30% and <50% of predicted value
In COPD patients, GOLD 4 very severe: FEV1 <30% of predicted value
Dose for albuterol when used as a rescue inhaler: 2-4 puffs every 4-6 hours as needed
Dose for albuterol when used in asthma exacerbation: 2.5-5mg every 20 minutes for 3 doses, then 2.5-5mg every 1-4 hours as needed
Brand name for DuoNeb: ipratropium bromide/albuterol
Duoneb dosing for mild-moderate COPD exacerbation: 3 inhalations every 6-8 hours as needed
Albuterol-Ipratropium dosing for severe COPD exacerbation: 3-4 inhalations every 4-6 hours as needed
Using macrolide antibiotics long-term can reduce exacerbations over 1 year
Dosing for azithromycin used to treat moderate or severe exacerbations: 500mg for 3 days, then 250mg for 4 days
When using antibiotics for moderate exacerbations, cover for: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
Recommended dose for prednisone for COPD exacerbation: 40-50mg/day for 5-7 days

Medication Frequency

Frequency dosing for Trelegy Ellipta: 1 inhalation daily
Frequency dosing for Breztri Aerosphere: 1 inhalation daily
Frequency dosing for Symbicort: 2 inhalations twice daily
Frequency dosing for Breo Ellipta: 1 inhalation daily
Frequency dosing for Spiriva HandiHaler: 1 inhalation daily
Frequency dosing for Spiriva Respimat: 1 inhalation twice daily
Frequency dosing for dexamethasone: 4-6 hours as needed

GINA Classification

Well-controlled according to GINA: symptoms 2-3 days/week, nighttime symptoms 2-3 times/month, and no limitations of daily activities
Partly controlled according to GINA: symptoms >3 days/week, nighttime symptoms >3 times/month, and some limitations of daily activities
Uncontrolled according to GINA: symptoms most days, nighttime symptoms most nights, and significant limitations of daily activities
4 symptoms to determine controlled, well-controlled, or uncontrolled according to GINA: daytime symptoms, nighttime symptoms, need for rescue medication, and limitation of daily activities

GOLD Assessment

If a patient has 2 or more moderate exacerbations, or 1 or more that lead to hospitalization, they belong to Category D
If a patient has 0 or 1 moderate exacerbations not leading to hospitalization, an mMRC of 0-1, and a CAT test <10, they belong to Category A
If a patient has 0 or 1 moderate exacerbations not leading to hospitalization, an mMRC >2, and a CAT test ≥10, they belong to Category B

GOLD Initial Pharmacological Treatment

Group E: triple therapy with ICS, LABA, and LAMA
Group A: short-acting bronchodilators as needed
Group B: short-acting bronchodilators as needed, and/or LABA, and/or LAMA

Social determinants of health for asthma: poverty, housing, education, and access to healthcare
Health disparities seen in asthma patients: socioeconomic status, race, and ethnicity

BB Warning

BB warning for montelukast: neuropsychiatric events, including suicidal thoughts and behavior

Discharge Management

Discharge management for asthma exacerbations: patient education, medication reconciliation, and follow-up appointment scheduling

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