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97 Cards in this Set
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- Back
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What are the phases of an asthma reaction?
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1) granule content release - histamine
2) membrane derived lipid mediators - leukotrienes 3) Cytokine production |
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When are symptoms for asthma the worse normally?
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Late at night (12am) and early in the morning.
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WHat are the types of aerosol inhaler medications for lung disease?
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1) pressurized metered dose
2) dry powder inhaler 3) nebulizer |
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What percentage of inhaled drug has effect on lung?
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10% (90% is swallowed an metabolized in liver)
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What type of aerosol drug deliver doesn't leave as much medication on the back of your throat?
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MDI + spacer
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How do b2 agonist work?
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increase cAMP which activates PKA and
1) activate calcium-activated K channels to hyperpolarize membrane so less excitable 2) Inhibit IP2-Ca pathway 3) Increase Na/Ca exchange 4) Increase Na/Ca ATPase 5) inactivate MLCK |
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Albuteral and Levalbuterol are taken how?
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via inhalation
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What is an oral b2 agonist you can take?
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Terbutaline
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Which stereioisomer of albuterol is the active B2 form?
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R-albuterol
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What is the onset of action for B2 agonist?
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inhlalation - 5-10 minutes
Duration of action - 2-6 hrs |
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How many puffs do you take of the short acting B2 agonist when you take them PRN?
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2 puffs, waiting a minute after first
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What should you give to severe asthma attacks, when they can't inhale anything?
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Terbutaline (or epinephrine) subcutaneoulsy
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What are the LABA mentioned?
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Almeterol
Fomoterol & Arformoterol (r form) |
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Which has a shorter onset of aciton, salmeterol or fomoterol?
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They are both LABA, but fomoterol is a little bit faster.
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Difference in LABA and SABA uses?
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LABA- regular schedule intervals
SABA - as needed |
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What is the once o day B2 agonist, and what is it commonly used for?
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Indacaterol, indicated for COPD
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What are the ASE of B2 drugs?
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Inhaled - cardiac/tremor
Oral - higher incident - tachycardia, angina, tremor, hypokalemia, angina |
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T/F - children are less sensitive to ASE of oral B2 drugs than adults
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true
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What are the mechanisms of action for theophyline (several)
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1) bronchodilator (inhibit PDE breakdown of cAMP)
2) Antiinflammatory - activate histone deacetylase, turns off inflammatory genes 3) inhibit adenosine receptors - which cause histamine and leukotriene release 4) strengthen respiratory muscles |
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Difficulty in prescribing theophyline?
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Narrow therapeuitc index
90% metabolized by liver Large variation in half life |
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What drugs affect theophylline metabolism?
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Erythromycin decreases metabolism
Phenytoin increases metabolism Cigarette smoking increases metabolism High chargrilled meat diet increases metabolism |
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Theophyliline SE?
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1) CNS excitation
2) weak diuretic 3) cardiac stimulation - positive chronotrope and inotrope 4) N&V |
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When do we (rarely) use theophylline?
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2ND line therapy
In COPD sometimes to strengthen respiratory drive Alos may decrease nocturnal asthma |
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What is the new PDE4 inhibitor and what is it used for?
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Roflumilast, used as adjunct to bronchodilator therapy in COPD assocaited with chronic bronchitis
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Side effects of Roflumilast?
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GI, Insomnia, Depression
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What cholinergic receptors do we want to block to treat respiratory disease?
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M3
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What happens when Ach binds to M3?
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It increases Ca-CM and activates MLCK, causes myosin light chain to contract
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What are the 2 major antimuscarinics.
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Tiotropium - blocks M3/M1
Ipratropium - blocks all M both approved for COPD |
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SE for Antimuscarinics?
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Dry mouth
Cough Nausea Bitter Taste |
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Mech of glucocorticoids?
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1) decrease inflammatory mediators
2) decrease vascular permeability 3) decreases mucous 4) increase B2 receptors |
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How do glucocorticoids work at a genetic level?
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1) inhibit histone acetyltransferase, and increase histone deacetylase activity
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when do you use inhalation vs oral steroids?
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1) inhalation - drug of choice for moderate to severe asthma
2) oral - super severe asthma or acute exacerbations |
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Side effects for Aerosol glucocorticoides
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Dysphonia
Oropharyngeal candidiasis (thrush) Bone resporption Adrenal suppression |
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T/F - pts on long term prednisone will require increased dose in times of stress?
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true
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Side effects of short term and long term steroid therapy?
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Short term - mood & appetite change, hyperglycemia, candidiasis
Long term - adrenal suppression, osteoporosis, glaucoma, cataracts, hyperglycemia, hypokalemia, muscle loss, immune suppression, purpura, skin fragility |
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how do steroids promote hyperglycemic effects?
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gluconeogenesis in the liver is stimulated, and breakdown of building blocks in other organs are sent to liver
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Tapering of steroid therapy is required for administerations of ORAL therapy after how longer?
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2-4 weeks (reduce dose 5-10mg every 2 wks)
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WHat do steroids do to calcium?
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1) decrease body calcium by decreasing abosprtion and increaseing excretion, and increasing bone catabolism
SO give them supplmental Calcium! when on steroids |
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Leukotrienes are a class of what molecule?
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Eicosanoids
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Leukotriene inhibitors mech?
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Inhibit leukotriene production (5lipox) or receptor, which inhibits plasam exudation, mucus secretion, bronchoconstriciton, and eosinophil recruitment
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When do you use CysLT1 receptor antagonist, and what is an example (the most common)?
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Use in mild persistent asthma, and it may reduce need for glucocorticoids in pts (eg. montelukast)
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What is The 5-lipoxygenase inhibitior mentioned, and when is it used?
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Zileuton
Not used as commonly as CysLT1 recpeotr antaognist, b/c it can cause flu like syndroe and requires liver funciton monitoring |
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What are the 2 cromones mentioned?
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Cromolyn and Nedocromil
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Mech of cromones?
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Inhibits mast cell mediator release
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Onset of action for cromones?
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2-3 months
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best use for cromones?
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- mild-moderate asthma
- exercise induced asthma -rhinoconjuctivitis |
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Anti-IgE antibody, given SC every 2-4 wks . Reserved for pts who don't respond to steroids.
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Omalizumab
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Risk w/ Omalizumab
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malignancy, anaphylaxis
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T/F - all but mildest forms of asthma are treated with drug that decreases inflammation.
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true
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What immunizations are recommended for COPD pts?
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inactivated influenza and 1/2 doses of pneumococcal vaccine
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T/F - you use steroids in all but the midlest forms of COPD?
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False. Only use steroids in COPD if it is severe (FEV1<50% w/ repeated exacerbations)
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What mucolytic is given in COPD to decrease exacerations and has antioxidant activity.
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N-acetylcysteine
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What is hte antidote for acetaminophen over dose?
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N-acetylcystein
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Treatment of allergic rhinitis.
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antihistamines
decongestants intranasal cromolyn intranasal anticholinergic intranasal and systemic glucocroticoids |
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What histamine receptors are present in bronchial tree?
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H1 (H2 in gastric parietal cells
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T/F - antihistamines are more prophylactic than anything.
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true.
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ASE of 1st gen antihistamines.
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Antimuscarinic effects -dry mouth, urinary retention, blurred vision, tachycardia, consitpations
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Common decongestants
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Sympathomimetics like phenylephrine and Oxymetazoline topically
Orally - pseudoephedrine |
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What is a cough suppresant chemically related to opiate agonist but acts at medually cough center
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Dextromethorphan
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How does Guaifenesin work?
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reduces viscosity and adhesiveness of secretions
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natural decongestants
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ephedra
bitter orange |
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Interstitial lung disease classes
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1) "known cause" - Pneumoconiosis, CVD, Drug-induced
2) IPF 3) associated with granulomas - sarcoidosis and HP? |
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What can being a Farmer and inhaling hay cause?
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Farmer's Lung - a hypersensitivity pneumonitis
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Drugs that cause ILD?
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- chemotherapy
- amiodarone - Nitrofurantoin (Abx) |
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Top 3 connective tissue diseases that cause ILD?
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RA
Scleroderma Polymyositis |
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What "other" things an cause ILD's?
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Lymphangioleyomyomatosis (LAM)
Tuberous Sclerosis Hermansky-Pudlak Syndrome |
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PE findings for ILD's?
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Cough (persistant)
Dyspnea Drugs Joint problems CLUBBING VElcro-like inspiratory rales |
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What are the different things you see on HRCT?
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1) ground glass opacifications - more inflammation/more cells
2) reticular opacities - some inflammation, some fibrosis 3) honeycombing - mostly established fibrosis |
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Where might you see ground glass opactiies?
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Acute interstitial pneumonia, Acute hypersensitivity pneumonitiis, CTD-ILD
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Where might you see reticular opacifications?
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NSIP (non-spepcific interstitial pneumonitis), IPF, CTD
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Where might you see honeycombing of lungs?
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IPF!
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Where is usual interstitial pneumonitis seen (UIP)?
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In IPF
Bad prognosis |
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Where is non-specific interstiital pneumonitis seeN/
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CTD (RA, Scleroderma, etc.)
Better prognosis that UIP |
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Where do you see BOOP (bronchioitis obliterans with organiziing pneumonia)
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Cryptogenic organizing pneumonia (COP), resolving infections, CTD, drug reactions
Great prognosis |
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Where do you see granulomatous inflammation?
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Sarcoidsosi
hypersensitivity pneumonitis MB and fungi |
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Most common pathologic finding in CTD?
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NSIP
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T/F - CTD has better prognosis than IPF
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true
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When do you test for when looking for RA?
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Rheumatoid factor and Anti-cyclic cytrullinate peptide (CCP)
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Where do you see ILD with RA?
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more common in men with RA, who have high RF tiger, with subcutaneous nodules
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T/F - steroids dont' help in RA ILD.
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false, they help some
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What organs are commonly involved in scleroderma?
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esophagus
lungs heart (b/c of pulmonary HTN) Raynaud's (hands) |
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What predicts poor prognosis in scleroderma?
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pulmonary HTN
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Where do you get skin thickening and glassy appearance of skin?
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Scleroderma
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How does scleroderma lead to ILD
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May stem from esophageal dysmotility and aspiration, but whatever it is, lung impairmenet happens in 90% of those with scleroderma.
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T/F - risk of bronchogenic cancer increased in scleroderma
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true
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T/F - most cases of asbestosis are progressive
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true, after a long latency period of 15-20 yrs
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T/F - use steroids in asbestosis
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false
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What do you see on lung biopsy for IPF?
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UIP
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Who commonly gets IPF?
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older caucasians
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What are the guidelines (general) for diagnosing IPF.
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1) patient >50, showing honeycomb on HRCT
2) NO secondary causes - CTD, asbestos, etc 3) Pt likely has IPF, NO BIOPSY NEEDED |
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Do you use steroids in IPF?q
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nope
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T/F - IPF patients have worse survival post lung transplant than other diseases
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True
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In the US, who mainly gets sarcoidosis (10X more likely)?
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African americans
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What enzyme correlates with severity of sarcoidosis?
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ACE
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How can you be sure something is sarcoidosis?
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CD4:CD8 ration >2
Keep cultrues for AT LEAST 8 WEEKS!! Negative stain does not rule out infection |
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Most stages of sarcoidosis have good remission rate, T/F?
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true
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T/F- you SHOULD use steroids for sarcoidsosi
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false, not evidence
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