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Wheezing- abnormal breath sound 2. Cough- too much production to be expectorated 3. Dyspnea- difficulty of breathing, air trapping decrease airway Characteristics: 1. Inflammation- swelling, diameter, increase mucous secretion 2. Airway hyper reactivity-sensitivity 3. Bronchoconstriction- smooth muscle line, the airway would be contracting 4. Allergic Reaction 5. IgE antibodies- exposure an allergen reacts with mast cell- attached antibodies release of substance leads the ff: y localized edema in the walls of the small bronchioles (corticosteroids) y secretion of thick mucous into the bronchiolar lumens y spasm of the bronchiolar smooth muscle (relaxant to dilate airway ) *inflammation- mucous production decrease airway, expiration Asthma classification 1. Mild intermittent- occasional, mild symptoms 2. Mild persistent- once a week, night symptoms 3. Moderate persistent maintenance 4. Severe persistent- daily COPD- irreversible, damage have been done, damage can t be cure Classification 1. Chronic Bronchitis bluish, blue bloater. productive cough for at least 3 mos. for 2 consecutive years 2. emphysema- destruction of parenchyma,alveolar sac/ damage of alveoli, pink, It results from ff: *Chronic infection of the cilia of the respiratory epithelium by the effects of nicotine *excessive mucous secretion *inhibition of alveolar macrophages 3. Obstruction leads to entrapment of air in the alveoli and overstretching them Drugs used in Asthma Classification 1. C ontrollers/Preventers y Corticosteroids y Long Acting Bronchodilators- long acting beta agonist and theophylline y Stimulate Muscarinic Receptor y Combined Corticosteroid and Long Acting Bronchodilators Formeterol + Budenoside (Symbicort turbuhaler); Salmeterol+ Fluticasone (Seretide diskus) y Leukotriene Receptor Agonist Montelukast+ Zafirlukast 2. Relievers y Short-acting bronchodilators- short acting beta agonist and short acting theophylline y Anti-cholinergic drugs- Ipratropium bromide (Atrovent) y Combined anti-cholinergic & Short acting beta agonist- Ipratropium bromide + Salbutamol (Combivent & short acting beta agonist) y Sympathomimetic Agent
COPD NOTES treatment 1. Short actingF2 agonist and anticholinergic drugs- for acute symptoms 2. Long acting F2 agonist (Salmeterol) or long acting anticholinergic (Tiotropium) for persistent symptoms 3. Theophylline- improves contractile function of diaphragm primary respiratory muscle, contraction increase space thoracic space to allow air to come in 4. Nasal Oxygen- 100% of oxygen is not given prolong the survival increase high amount Oxygen- decrease respiratory drive. oxygen toxicity 5. Antibiotics- routine, infections MOA Sympathomimetic Agents Example 1.Epinephrine USES A/E CI DI OTHERS Effects of Sympathomometic Agent: *Relax airways smooth muscle *Inhibit release of bronchoconstricting from mast cells *Inhibit microvascular leakage(prevent edema) *edema- too much leakage in the capillary *increase mucociliary transport increase ciliary activity (Flush out the mucous) * Activate adenylyl cyclase increase cAMP relaxation of Smooth muscle
*Rapid acting *Non-selective agonist E1,F1,F2 *Stimulates E1,F1,F2 receptors Cardiovascular effects(tachycardia, increase blood pressure, increase heart rate) *Longer duration
2. Ephedrine
*oral *less potent than epinephrine *maximal bronchodilation in 5 mins *rarely used *Increase in mortality due to cardiac arrhythmias
3.Isoproterenol
F2 selective Drugs
*Skeletal muscle tremor F2, stimulate contraction, increase glycogenolysis *nervousness, weakness
*inhaled/Oral *inhaled/Oral
4.Pirbuterol *Long Acting 1. Salmeterol 2.Formeterol Methylxanthines *Inhibit several members of the phosphodiesterase enzyme (esp. PDE4) family increase cAMP (bronchoconstriction) - stimulate cardiac functionpalpitation - smooth muscle relaxation -reduction of inflammation *inhibit adenosine receptor *anorexia, nausea, vomiting (too much acid secretion), abdominal discomfort, headache, anxiety Effects *CNS- mild cortical arousal, increase alertness & deferral of fatigue *CV- +chonotropy & inotropy(force of contraction) *GIT- stimulate gastric acid & digestive enzyme secretion *Kidney weak dieresis (theophylline) *SM- bronchodilation: inhibit antigen- induced release histamine *Skeletal muscle- improve contractility & reverse fatigue of the diaphragm in COPD pxs
Example 1.Theophylline
*most selective; narrow therapeutic window; improves long-term control of asthma, inexpensive,
*can be taken orally *emergency situation are not given, should check on plasma level/blood level
2. Theobromine 3.Caffeine 4.Aminophylline Antimuscarinic Agent *competitively inhibit the effect of the acetylcholne at muscarinic receptor *stops constriction, promote bronchodilation --blocks the contraction of airway Smooth muscle promote bronchoconstriction -- blocks the increase in mucus
*enhance bronchodilation produced by nebulized albuterol *longer acting; for COPD; alternate to long acting F2 treatment of asthma *inhibit inflammatory cytokines *oropharyngeal candidiasis Leads to:
Corticosteroid
*hoarseness *increase risk of osteoporosis and cataracts Example 1.Prednisone 2.Beclomethasone 3.Budenoside 4.Ciclesonide 5.Fluniconide 6.Ciclesonide 7.Fluticasone 8.Mometasone 9.Triamcilone
*Alters the function of delayed Cl channels and inhibits inflammatory cell activation *Inhibit mast cell degranulation
*Reduce bronchial activity * Inhibit infiltration of asthmatic airways by lymphocyte, eosinophil (allergic rxn)and mast cell (release of inflammatory mediator) *can have severe S/E when given chronically; reserved for patients who require urgent treatment *refractory to treatment *adrenal suppression- adrenal cortex glands secretes aldosterone, cortisols, sex hormone
*Inhibit of 5- lipoxygenase, prevenet leukotriene synthesis *least prescribed because of hepatotoxicity *inhibit binding of LTD4 to its receptor in target tissue *inhibit the binding of IgE to mast cells; does not provoke mast cell degranulation *IgE- release inflammatory mediation Benefits: *lower IgE to undetectable Levels *reduces the magnitude of early and late bronchospastic responses to antigen challenge
Example 1.Omalizumab
DRUGS USED IN ACID PEPTIC DISEASES HISTOLOGY 1. chief cells pepsin (enzyme), important in digestion 2. parietal cell- secreting HCl 3. Antral G cell- Gastrin 4. Antral D cell- Somatostatin 5. Enterochromaffin like cell (ECL)- Histamine Gastric Physiology Stimulated by: 1. Gastrin 2. Acetylcholine 3. Histamine Control of Acid Secretion 1. Somatostatin increase luminal pH concentration send signal, inhibits gastrin release 2. CCK (Cholecystokinin)- presence of protein and fats in the duodenum release of CCK to stop acid secretion Protective Barriers of the Stomach 1. Mucus- goblet 2. Mucosal Lining- simple columnar, prostaglandin will stimulate lining Acid Peptic Diseases 1. Peptic ulcer Disease 2. Gastroesophageal Disease 3. Gastritis- Acute & Chronic Approach Treatment 1. reduce the intragastric acidity y Antacid & H2 antagonist (Histamine 2 Receptor), y PPI- release HCl in parietal cell 2. Promote mucosal defense y Sucralfate protective barrier y Prostaglandin- allow regeneration of mucosal lining 3. Kill offending organism- associated with Helicobater pylori y antibiotic MOA USES A/E Antacid *neutralizes gastric acid Example 1.Sodium bicarbonate *produce sodium chloride and *belching& gastric carbon dioxide distention *potential cause of metabolic acidosis (milk alkali syndrome)
CI
DI
OTHERS
2.Calcium Carbonate
*Produce magnesium chloride and water *produces Aluminum choride and water *competitively inhibit parietal cell H2 receptor *diminish gastrin & acetylcholine effect on gastric secretion *can cross placenta *GERD * PUD- promote healing *Gastritis *Comatose, critically ill
*hypercalcemia, renal insufficiency, metabolic acidosis (milk alkali syndrome) *osmotic diarrhea, tend to pull water *constipation Effect 1.Reduce nocturnal acid secretion (at night when sleeping since food is already digested) 2.Reduce meal- stimulated acid secretion
H2 receptor Antagonist
*inhibits binding of dihydrotestosterone to androgen receptor Gynecomastia *Inhibit metabolism of estradiol, increase prolactin level gynecomastia, impotence, galactorrhea
*irreversible direct inhibition of the proton- pump (K/H antiporter) in the gastric parietal cell * Longer duration of action
*GERD *PUD- rapid symptom relief and ulcer healing - for H.pylori associated ulcer - NSAID- associated ulcer - prevention of rebleeding *Non-ulcer dyspepsia *Stress- related Mucosal bleeding *Gastrinomas- Zollinger Ellison Syndrome
*Ketoconazole/ItraconazoleAntifungal *Digoxin(Lanoxin)- Cardiac glycoside *Atazanavir- antiviral *decrease elimination of diazepam, warfarin & phenytoin
Characteristic *Administered as prodrugs *Formulation acid resistant, enteric- coated capsules/ tablets *Bioavailability decrease 50take on an empty stomach *Inhibits both fasting and meal-stimulated acid secretion