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A Wisp of Air: Review of Respiratory Medication
Kathy Tripepi-Bova MSN, RN, CCRN, CCNS
Keith Anderson PharmD
Disney wikia art
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Functions
• provide oxygen to the blood stream and remove carbon dioxide
• enable sound production or vocalization as expired air passes over the vocal chords
• enable protective and reflexive non-breathing air movements such as coughing and sneezing, to keep the air passages clear
• control of Acid-Base balance in the blood and thus control the blood pH
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One breath
• Normal respiratory rate is 10- 15 breaths per minute.
• For inspiration, the inspiratory center sends nerve impulses along the phrenic nerve to the diaphragm and along the intercostal nerves to the external intercostal muscles to stimulate inspiration (2 seconds)
• For expiration the inspiratory center stop firing for about 3 seconds which allows the muscle to relax and the lungs to recoil
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Lower airways
•www.aduk.org.uk/ gfx/lungs.jpg
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http://histology.med.umich.edu/medical/respiratorysystem&docid=JPBVlGa23XXLpM&w=850&h=562&ei=OhSCTv3yHqP-sQKQxuSbDw&zoom=1
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Respiratory System – alveoli
http://www.livinghealthfully.com/2012-02/
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Lining of the alveoli
• Type I cells or Type I alveolar cells
– Make up 97% of the alveolar surface
– Very thin components of the blood air barrier
– Coated by a thin layer of water
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• Surfactant: a lipoprotein that is produced in the lungs Produced by Type II cells Cover the remaining 3% of the alveolar surface reduces the surface tension of fluid in the lungs and
prevents the alveoli from collapsing Production begins in utero at about 20 weeks gestation
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• Macrophages
– important in removing any debris that escapes the mucus and cilia in the conducting portion of the system
– Also known as dust cells
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http://quizlet.com/15237551/respiratory-system-flash-cards/
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http://www.studydroid.com/index.php?page=viewPack&packId=539058
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AIRWAY DISEASES
COPD and Asthma
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Bronchitis
• Airway changes lead to hypersecretion of mucus and impaired cilia which lead to a chronic productive cough
• Bronchial wall thickening leads to progressive obstruction to air flow
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“Blue bloater”
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COPD-Emphysema
• A loss of elasticity in the walls of the small air sacs in your lungs. – Eventually, the walls stretch and break, creating larger, less
efficient air sacs that aren't able to handle the normal exchange of oxygen and carbon dioxide.
• When emphysema is advanced, the patient must work hard to expel air from their lungs
• Breathing can consume up to 20 percent of the resting energy.
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Altered dynamics of breathing
• Diaphragm is pushed down
• Intercostal space enlarges as lung expands
• Must use neck muscles to aid in respiration
• “Purse lip breathing” on exhalation
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Pink puffer
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COPD-Emphysema
• Primary signs and symptoms
– shortness of breath
– or the feeling of not being able to get enough air
• Treatments focus on relieving symptoms and avoiding complications.
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Asthma
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Definition of asthma
• a chronic inflammatory disorder of the airways that involves many different cells, including mast cells, eosinophils, and T lymphocytes
• inflammation causes recurrent episodes of wheezing, dyspnea, and cough
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Pathogenesis
• Airway inflammation with airway reactivity
– contraction of the airway smooth muscles
– microvascular leakage
– bronchial hyper-responsiveness
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• Asthma differs from other airway diseases because of
– absence of bronchiolitis
– lack of fibrosis
– absence of granulation tissue
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Early asthma response (EAR)
• With exposure to a trigger, there mobilization of histamines, prostaglandin and leukotrienes.
• This causes – Airway smooth muscle constriction
– Mucous hypersecretion
– Mucosal edema
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Late asthma response (LAR)
• Includes mobilization of lymphokines and other chemotactic compounds that may cause lymphocytes, neutrophils and eosinophils to migrate to the site of airway hyperreactivity
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LAR results in
• Damage to the respiratory epithelium
• Amplification of the inflammatory process
• Propagation of the inflammatory response along other airways
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Goals of Asthma Therapy
• Prevent chronic symptoms such as cough and wheezing
• maintain near normal pulmonary function
• maintain normal activity levels-this includes exercise
• Prevent recurrent exacerbation
• Provide optimal pharmacotherapy with minimal side effects
• Meet patients and families expectations of satisfaction with asthma care
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Prevent and decrease
symptoms
Reduce frequency and
severity of exacerbations
Improve health status
Improve exercise capacity
Global strategy for the diagnosis, management, and prevention of COPD: Revised 2014. Global initiative for Chronic obstructive lung disease (GOLD). http://www.goldcopd.org (Accessed October 25, 2014)
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Stage Characteristics
I: Mild COPD FEV1 ≥ 80% predicted
II: Moderate COPD 50% ≤ FEV1 < 80% predicted
III: Severe COPD 30% ≤ FEV1 < 50%
IV: Very Severe COPD FEV1 < 30% predicted
In Patients with FEV1/FVC < 70%
Global strategy for the diagnosis, management, and prevention of COPD: Revised 2014. Global initiative for Chronic obstructive lung disease (GOLD). http://www.goldcopd.org (Accessed October 25, 2014)
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Patient Characteristic Spirometric Classification
Exacerbations per year CAT mMRC
A Low Risk Less Symptoms
GOLD 1-2 ≤1 <10 0-1
B Low Risk More Symptoms
GOLD 1-2 ≤1 ≥10 ≥2
C High Risk Less Symptoms
GOLD 3-4 ≥2 <10 0-1
D High Risk More Symptoms
GOLD 3-4 ≥2 ≥10 ≥2
Global strategy for the diagnosis, management, and prevention of COPD: Revised 2014. Global initiative for Chronic obstructive lung disease (GOLD). http://www.goldcopd.org (Accessed October 25, 2014)
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Patient Group
Recommended 1st Choice Alternative Choice Other Possible Treatments
A • SA anticholinergic prn or • SA β2-agonist prn
• LA anticholinergic or • LA β2-agonist or • SA anticholinergic and SA β2-agonist
• Theophylline
B • LA anticholinergic or • LA β2-agonist
• LA anticholinergic and LA β2-agonist • SA anticholinergic
and/or SA β2-agonist • Theophylline
C • ICS + LA β2-agonist or • LA anticholinergic
• LA β2-agonist and LA anticholinergic or • LA anticholinergic and PDE-4 Inhibitor or • LA β2-agonist and PDE-4 Inhibitor
• SA anticholinergic and/or SA β2-agonist
• Theophylline
D
• ICS + LA β2-agonist and/or LA anticholinergic
• ICS + LA β2-agonist and PDE-4 Inhibitors or • LA anticholinergic and LA β2-agonist or • LA anticholinergic and PDE-4 Inhibitor
• Carbocysteine • SA anticholinergic
and/or SA β2-agonist • Theophylline
Global strategy for the diagnosis, management, and prevention of COPD: Revised 2014. Global initiative for Chronic obstructive lung disease (GOLD). http://www.goldcopd.org (Accessed October 25, 2014)
SA=short acting LA=long acting ICS=inhaled corticosteroid PDE=phophodiesterase inhibitor
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Short acting β2 agonists
Medication Usual dose Duration
Albuterol MDI: 2 puffs q4-6 hours Nebulization: 2.5mg q6-8 hours
4-6 hours
Levalbuterol MDI: 2 puffs q4-6 hours Nebulization: 0.63-1.25mg TID
6-8 hours
Long acting β2 agonists
Formoterol Foradil Aerolizer: 12mcg q12 hours Perforomist: 20mcg BID
12 hours
Arformoterol 15mcg BID 12 hours
Indacaterol 75-300mcg daily 24 hours
Olodaterol 5mcg daily 24 hours
Salmeterol 50mcg q12 hours 12 hours
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Short acting anticholinergics
Medication Usual dose Duration
Ipratropium MDI: 2 puffs 4-6X daily Nebulization: 2.5mL 3-4X daily
6-8 hours
Long acting anticholinergics
Tiotropium Handihaler: 18mcg daily Respimat*: 5mcg daily
24 hours
Aclidinium 400mcg BID 12 hours
*Available 1/15
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ICS + LA β2 agonists
Medication Usual Dose
Budesonide/salmeterol 160/4.5mcg BID
Fluticasone/salmeterol* 250/50mcg BID
Fluticasone/vilanterol 100/25mcg daily
Mometasone/formoterol** 10/200mcg-10/400mcg BID
SA anticholinergic + SA β2 agonists
Ipratropium/albuterol Respimat: 1 inhalation 4-6X daily Nebulization: 3mL 4-6X daily
LA anticholinergic + LA β2 agonists
Umeclidinium/vilanterol 62.5/25mcg daily
*DPI dose (MDI not approved for COPD) **Not FDA approved for COPD
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Global strategy for the diagnosis, management, and prevention of COPD: Revised 2014. Global initiative for Chronic obstructive lung disease (GOLD). http://www.goldcopd.org (Accessed October 25, 2014) N Engl J Med. 2011; 365(8): 689–698
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Global strategy for the diagnosis, management, and prevention of COPD: Revised 2014. Global initiative for Chronic obstructive lung disease (GOLD). http://www.goldcopd.org (Accessed October 25, 2014) Ann Pharmacother. 2012 Dec;46(12):1717-21
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Global strategy for the diagnosis, management, and prevention of COPD: Revised 2014. Global initiative for Chronic obstructive lung disease (GOLD). http://www.goldcopd.org (Accessed October 25, 2014)
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N Engl J Med. 1999;340(25):1941-7 Chest. 2007;132(6):1741-7 JAMA. 2010 Jun 16;303(23):2359-67 Am J Respir Crit Care Med. 2014;189(9):1052-64 JAMA. 2013;309(21):2223-31
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Reduce impairment • Prevent chronic and
troublesome symptoms • Require infrequent use of
SA β2 agonists • Maintain normal lung
function • Maintain normal activity
levels
Reducing Risk • Prevent recurrent
exacerbations • Minimize need for ED
visits/hospitalizations • Prevent progressive loss of
lung function • Provide optimal therapy
with minimal or no adverse effects
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Components of severity
Intermittent Persistent
Mild Moderate Severe
Symptoms ≤2 days/week >2 days/week but not daily
Daily Throughout the day
Nighttime awakenings
≤2x/month 3-4x/month 1x/week but not nightly
Often 7x/week
SA β2 agonist use ≤2 days/week >2 days/week, but not daily or >1x/day
Daily Several times per day
Interference with normal activity
None Minor limitation Some limitation Extremely limited
Lung function
• FEV1 > 80% predicted
• FEV1 /FVC normal
• FEV1 > 80% predicted
• FEV1 /FVC normal
• FEV1 > 60% but <80% predicted
• FEV1 /FVC reduced 5%
• FEV1 > 60% predicted
• FEV1 /FVC reduced >5%
Exacerbations requiring systemic corticosteroids
0-1/year ≥2/year
Recommended step for initiating treatment
Step 1 Step 2
Step 3 Step 4 or 5
And consider short course of oral systemic corticosteroids
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute; Revised August 2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed October 25, 2014
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National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute; Revised August 2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed October 25, 2014
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Drug Low Daily Dose Medium Daily Dose High Daily Dose
Beclomethasone HFA 80-240mcg >240-480mcg >480mcg
Budesonide DPI 180-600mcg >600-1200mcg >1200mcg
Fluticasone HFA: 88-264mcg DPI: 100-300mcg
HFA: >264-440mcg DPI: >300-500mcg
HFA: >400mcg DPI: >500mcg
Mometasone DPI 200mcg 400mcg >400mcg
• Clinical effects – Decreased severity of symptoms
– Improved asthma control and quality of life
– Improved PEF and spirometry
– Diminished airway hyper-responsiveness
– Prevention of exacerbations
– Reduction in systemic corticosteroid courses, ED care, hospitalizations, and deaths due to asthma
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Medication ICS dose Usual dose
Fluticasone/salmeterol DPI Low-medium dose 100/50mcg BID
Medium-high dose 250/50-500/50mcg BID
Fluticasone/salmeterol HFA Low-medium dose 45/21mcg BID
Medium-high dose 115/21-230/21mcg BID
Budesonide/formoterol Low-medium dose 160/9mcg BID
Medium-high dose 320/9mcg BID
Mometasone/formoterol Medium dose 200/10mcg BID
High dose 400/10mcg BID
*LA β2 agonists should not be used as monotherapy
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Medication Dose
Albuterol
MDI: 4-8 puffs every 20 minutes up to 4 hours, then every 1-4 hours prn Nebulizer: 2.5-5mg every 20 minutes X3 doses, then 2.5mg every 1-4 hours prn, or 10-15mg/hr continuously
Levalbuterol 1.25-2.5mg every 20 minutes X3 doses, then 1.25-5mg every 1-4 hours prn
Ipratropium+albuterol 3mL every 20 minutes X3 doses, then as needed
Corticosteroids (methylprednisolone, prednisolone, prednisone)
40-80mg daily until PEF ≥70% of predicted personal best
• SA β2 agonists recommended for all patients – Mild-moderate exacerbations may use MDI or nebulizer
– Nebulizer for severe exacerbations
• Ipratropium – Recommended in ED for up to 3 hours for severe exacerbations
– Not recommended for hospitalized patients
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