Disney wikia art
A Wisp of Air: Review of Respiratory
Medication
Kathy Tripepi-Bova MSN, RN, CCRN, CCNS
Keith Anderson PharmD
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
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
Lower airways
•www.aduk.org.uk/
gfx/lungs.jpg
http://histology.med.umich.edu/medical/respiratorysystem&docid=JPBVlGa23XXLpM&w=850&h=562&ei=OhSCTv
3yHqP-sQKQxuSbDw&zoom=1
Respiratory System – alveoli
http://www.livinghe
althfully.com/201202/
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
• 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
• Macrophages
– important in removing any debris that escapes the mucus
and cilia in the conducting portion of the system
– Also known as dust cells
http://quizlet.com/15237551/respirator
y-system-flash-cards/
http://www.studydroid.c
om/index.php?page=vie
wPack&packId=539058
COPD and Asthma
AIRWAY DISEASES
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
“Blue bloater”
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.
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
Pink puffer
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.
Asthma
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
Pathogenesis
• Airway inflammation with airway reactivity
– contraction of the airway smooth muscles
– microvascular leakage
– bronchial hyper-responsiveness
• Asthma differs from other airway diseases because
of
– absence of bronchiolitis
– lack of fibrosis
– absence of granulation tissue
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
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
LAR results in
• Damage to the respiratory epithelium
• Amplification of the inflammatory process
• Propagation of the inflammatory response along
other airways
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
Prevent and
decrease
symptoms
Improve health
status
Reduce
frequency and
severity of
exacerbations
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)
In Patients with FEV1/FVC < 70%
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
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)
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)
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
•
SA anticholinergic
and/or SA β2-agonist
Theophylline
• 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
C
•
D
ICS + LA β2-agonist
and/or LA
anticholinergic
SA=short acting
LA=long acting
ICS=inhaled corticosteroid
PDE=phophodiesterase inhibitor
LA anticholinergic and LA β2-agonist
• ICS + LA β2-agonist and PDE-4 Inhibitors
or
• LA anticholinergic and LA β2-agonist
or
• LA anticholinergic and PDE-4 Inhibitor
•
•
•
•
•
•
SA anticholinergic
and/or SA β2-agonist
Theophylline
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)
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
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
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
*DPI dose (MDI not approved for COPD)
**Not FDA approved for COPD
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
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
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
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. 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
Reduce impairment
Reducing Risk
•
•
•
•
•
Prevent chronic and
troublesome symptoms
Require infrequent use of
SA β2 agonists
Maintain normal lung
function
Maintain normal activity
levels
•
•
•
Prevent recurrent
exacerbations
Minimize need for ED
visits/hospitalizations
Prevent progressive loss of
lung function
Provide optimal therapy
with minimal or no
adverse effects
Components of
severity
Intermittent
Symptoms
Persistent
Mild
Moderate
Severe
≤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
•
•
•
•
FEV1 > 80%
predicted
FEV1 /FVC
normal
Lung function
•
Exacerbations
requiring systemic
corticosteroids
0-1/year
Recommended
step for initiating
treatment
•
FEV1 > 80%
predicted
FEV1 /FVC
normal
•
FEV1 > 60% but
<80% predicted
FEV1 /FVC
reduced 5%
≥2/year
Step 3
Step 1
•
FEV1 > 60%
predicted
FEV1 /FVC
reduced >5%
Step 2
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
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
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
Medication
Fluticasone/salmeterol DPI
Fluticasone/salmeterol HFA
Budesonide/formoterol
Mometasone/formoterol
ICS dose
Usual dose
Low-medium dose
100/50mcg BID
Medium-high dose
250/50-500/50mcg BID
Low-medium dose
45/21mcg BID
Medium-high dose
115/21-230/21mcg BID
Low-medium dose
160/9mcg BID
Medium-high dose
320/9mcg BID
Medium dose
200/10mcg BID
High dose
400/10mcg BID
*LA β2 agonists should not be used as monotherapy
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