A Wisp of Air: Review of Respiratory Medication
Kathy Tripepi-Bova MSN, RN, CCRN, CCNS
Keith Anderson PharmD
Disney wikia art
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=OhSCTv3yHqP-sQKQxuSbDw&zoom=1
Respiratory System – alveoli
http://www.livinghealthfully.com/2012-02/
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/respiratory-system-flash-cards/
http://www.studydroid.com/index.php?page=viewPack&packId=539058
AIRWAY DISEASES
COPD and Asthma
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
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)
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)
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
• 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
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
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
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 • 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
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
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 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
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