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?????