KEY POINTS FOR PEBC EXAM
RESP QUICK LESSON
Obstructive lung disease FEV1/FVC <0.7
Asthma
Patho Severity based on level of tx required to achieve sx control
i. Mild: well controlled w short-acting BD PRN, low dose ICS or LTRA
ii. Mod: well controlled w low dose ICS/LABA
iii. Severe: high dose ICS/LABA
Sx: 12% FEV1 ↑ post-BD
Risk GERD, fam hx, atopic triad
Exacerbations high SABA use, inadeq CS, poor adherence, incorrect technique, comorbs
(obesity, chronic rhinosinusitis, GERD, allergy, preg), exposures (smoking,
allergens), major psych/SE, low lung fx, ever intubated/ICU, >1 severe
exacerbation in last 12mo, FEV1 <60%, high BD rev
Drug NSAIDs/ASA/COX-2, tartrazine, sulfites, BB (unless very well controlled
asthmatic cardioselective: metoprolol, bisoprolol, atenolol)
Nonpharm Avoid precip factors, smoking cess, treat modifiable risk (obesity, anx, depression, GERD, chronic
rhinosinusitis, OSA)
Flu, pneumo vax
Immunotherapy: mb useful for concomitant allergic rhinitis (mod-sev) >5yo
Treatment SABA monotherapy NR all adults/adols should have an ICS-containing regimen
SAMAs: can be used in addition to SABA for acute exacerbations, alt for those susceptible to
tremor/tachy
LAMA: add-on despite mtn
LTRA: add on for mod-sev w ICS, 2nd line mono after daily low-ICS or PRN ICS/LABA, add on to low
dose ICS in concomitant rhinitis
- Can be used >2yo
Adults
Adults: + LABA before ↑ ICS *no LABA monotherapy
Always: PRN low dose ICS-formoterol (other: SABA)
Step 1: PRN low dose ICS-formoterol (max 6inh on one occasion, max 8/day)
- >6yo
Step 2: daily low dose ICS or PRN low dose ICS-formoterol
- LTRA or low dose ICS whenever SABA is taken
Step 3: low dose ICS-LABA
- Med dose ICS or low dose ICS+ LTRA
- LABAs only for pts already taking ICS (mono ↑ death), may be ICS sparing
Step 4: medium dose ICS-LABA
- High dose ICS, add on tiotropium or LTRA
Pediatrics
Pediatrics: ↑ ICS dose before + LABA
Step 1: low dose-ICS whenever SABA is used
Step 2: daily low dose ICS
- LTRA or low-dose ICS when SABA used
Step 3: low dose ICS-LABA or medium dose-ICS
- Low-dose ICS + LTRA
Step 4: medium dose ICS-LABA
- High dose ICS or + tiotropium or + LTRA
Exacerbations
SABA (4-10 puffs) via spacer at ↑ doses q20min, PO pred (25-50mg x 7-14d), ↑ controller med/↑dose x
>2-4wks
- +/- ipratropium
Oxygenation
Monitoring Sx control over past 4 wks
- Daytime asthma sx >2x/wk, reliever needed >2x/wk
- Any nocturnal awakening
- Any activity limitation, missing school/work
- PEF <90% predicted
, Step up: check inhaler technique, adherence, comorbs, exposure to irritants
- Inhaler technique: shake, hold breath 5-10s, if 2nd puff req wait 15-30s
- Spacer: whistling sound indicates breathing that is too fast
Step down: sx controlled for 3mo + low risk of exacerbations
- Ceasing ICS NR
ICS: 4-6 wks
ICS
Dose
ADR Spacer ↓ dysphonia and candidiasis
DI Strong CYP3A4 (except beclomethasone)
COPD
Patho - <12% post-BD FEV1 ↑ (<70%)
- Spiro may improve but never normalize
mMRC
1. Only breathless w strenuous exercise
2. SOB hurrying on level ground, walking up a hill
3. Slower than most
4. Stop for breath after 100m level
5. Too breathless to leave house
Group A: mMRC 1-2 or CAT <10 with 0 or 1 exacerbations in past y (not leading to hospital admit)
Group B: mMRC >3 or CAT >10 with 0 or 1 exacerbations in past y (not leading to hospital admit)
Group C: mMRC 1-2 or CAT <10 with >2 exacerbations in past y (or hospital admit) or >1 in past y
leading to hospital admission
Group D: mMRC >3 or CAT >10 with >2 exacerbations in past y (or hospital admit) or >1 in past year
leading to hospital admission
Acute Exacerbations
Mild: resolved using short-acting BD alone
Mod: use of abx and/or PO CS
Severe: hosp or ER dt underlying resp failure
Risk Smoking, air pollution, long term dust/chemical exposure, A1AT deficiency, >40yo
Drug (exacerbate/mimic): BB, ACEI
Nonpharm Spiro w BD for: smokers >35yo, past smokers w >20 pack year hx, recurrent/chronic resp sx, fam hx
COPD, significant occupational exposure
Flu, pneumo vax
PR programs for groups B-D
Lung resection: improve survival, ↓ hyperinflation, improve exercise capacity
Treatment Address risk factors, self-management, exercise, education
A. BD
B. LABA or LAMA (first line) LAMA + LABA
C. LAMA LAMA + LABA (OR LABA + ICS)
- ICS: may ↓ exacerbation freq, has been assoc w PNA
D. LAMA + LABA + ICS
Acute Exacerbations
Hosp: periph edema/cyanosis, use of accessory inspiratory muscles, comorbid HF
SOB: SABA + SAMA
Severe COPD: pred x 5d wi 30 days of exacerbation
Severe exacerbation + 2 of (↑ sputum purulence OR V, worsening SOB): abx (strep pneumo, H flu, m
, cat)
- Broad spectrum abx sb provided in complicated exacerbations (IHD, FEV <50%, home O2)
- Consider class change if abx in past 3mo
i. <4 exacerbations in past y (haemophilus, m cat, strep pneumo): amox x 5-7d, doxy x
5-7d, SMX/TMP x 5-7d
ii. >4 exacerbations in past y, failure of first agent, abx in past 3mo (+ enterobac,
pseudomonas): amoxclav x 5-10d, cefuroxime x 5-10d, levoflox x 5d, (OR: azithro x
3d, clarithro x 5-10d)
- Gram neg (Klebsiella-advanced age, FEV1 <50%, >4 exacerbations/yr, IHD, home oxygen,
chronic PO CS use): amoxclav or 2g FQ (cipro if high suspicion for pseudomonas)
Allergic Rhinitis
Patho Intermittent: <4d/wk OR <4 consec wks
Persistent: >4d/wk OR >4 consec wks
Mod/severe: impaired activities
Refer <2yo, treatment failure/persistent (non-rx for 2wk), mod-sev, unilat, OM, uncontrolled asthma,
SOB/diff breathing, unilat sx, >40.5 high fever, severe HA/eye pain
Risk Drug: BB, ACEi, chlorpromazine, amitriptyline, ASA/NSAIDs, rebound from topical decongestants, alpha
blockers, oral contraceptives
Nonpharm Avoid allergens, avoid aggravating factors, nasal saline irrigation, lubricant eye drops, cold/warm
compresses
Immunotherapy: for severe diff to control allergic rhinitis and cannot avoid allergen
Using nasal sprays: gently blow nose, shake bottle, occlude one nostril, blow away from septum, rinse tip
w hot water and dry
Treatment Mild sx or <2mo PO AH + PO/IN decongestant
Mod/sev or >2mo IN CS + PRN AH + PO/IN decongestant for B/T + ophth AH /MCS for
conjunctival sx PRN
Rhinorrhea: INCS, anticholinergic, antihistamines most effective
- PO AH, LTRA, Intranasal mast cell stabilizers less effective
Congestion: INCS most effective
- Decongestants, LTRAs, PO AH, ophthalmic mast cell stabilizers less effective
- IN AC not effective at congestion
Nasal itching: INCS (most effective)
- Less effective: INMCS, PO AH, PO LTRA
- Decongestants and INAH not effective
Idiopathic rhinitis: IN anticholinergic + INCS
Agents OTC
PO AH 1gAH NR first line dt ADR
- Chlorpheniramine preferred in preg
DI CYP2D6 inh (amiodarone, celecoxib, bupropion, paroxetine)
- Diphenhydramine may ↑ CYP2D6 substrate (metoprolol, venlafaxine)
2gAH first line for mild allergic rhinitis >2yo
- Most effective if taken px
- Req renal dose adjustment, ↓ doses in liver impairment for loratadine
- Cetirizine and loratadine can still cause some sedation
- Loratadine preferred in preg
↑QT reported w amiodarone
- Fexofenadine dosed BID, avoid Al/Mg antacids
IN mast cell Onset 4-7d
stabilizers
Decongestants PO: avoid use in uncontrolled HTN or hyperthyroid, preg
- Do not use wi 2w of MAOI, ergot derivatives
- Can cause blood sugar changes
- Avoid use in 1T, <6yo
IN: do not use for more than 3-5d
Prescription
INCS First line for mod-sev peak effect in 1-2w (adeq trial 2-4w), give regularly and 1w
before allergen exposure
, - Children: best evidence for mometasone, fluticasone propionate
- preg: best evidence for beclomethasone/budesonide, potential risk w 1T
triamcinolone
beclomethasone does not have OD dosing
Anosmia usually not improved
IN AH >12yo
(levocabastine) If no improvement in 3d, DC (onset 10min)
IN Vasomotor rhinitis titrate dose to response
anticholinergic
LTRA Helpful if concomitant asthma or nasal polyps
Topical When PO AH, INCS, and LTRA do not improve conjunctival sx
ophthalmic AH - Discard cromoglycate wi 1mo
Do not use topical vasoconstrictors
Topical mast Several day onset, q6h intervals to maintain effect (IN)
cell stabilizers
Monitoring Sx improvement/resolution in 1w
Cough
Red Flags Uncontrolled COPD/asthma, CHF, GERD, hazardous chemicals/irritants, >3w, bloody sputum, SOB,
CP, vomiting/choking, acute alteration in mental status, recent 6mo ACEi/BB
PSYCH SHORT LESSON
Acute Agitation
Drug Antichol, CS, amantadine, DA/DA Ag
Opioid tox/withdrawal, BZD withdrawal
Non-Pharm Ensure safety det cause non-pharm measures
Verbal De-esc: respect personal space, do not be provocative, establish verbal contact, concise/simple
language, ID feelings/desires, listen closely, agree/agree to disagree, lay down law/set clear limits, offer
choices/optimism, debrief PT/staff
Pay attention to safety
- Speak in calm env, assist in controlling behavior, reassure they are in safe environment
Limit sedative use in dementia PTs
Pharm Reserve BZDs where sx are attributed to OH/BZD withdrawal
- Choose long half lives
Use ↓ doses of APh in elderly for shortest duration w close monitoring
***do not admin parenteral BZDs w IM olanzapine dt cardiac/resp complications
Delirium 1gAPh (haloperidol, loxapine) OR 2gAPh (olanzapine, risperidone, quetiapine)
- Haloperidol most studied
- Olanzapine and risperidone ODT
- Olanzapine IM
Dementia Only if risk of harm
- Use low doses and cautiously titrate
2gAPh (Risperidone) OR 1gAPh (Avoid in LBD) OR AChEI (LBD) OR memantine OR
trazodone
- Little evidence for quetiapine
- Haloperidol NR
2nd line: BZD (Lorazepam, oxazapem)
Brain Injury BB OR AED (CMZ, VPA) OR APh
- Avoid BZDs
Mental Mania: 2gAPh OR 1gAPh + lorazepam WITH/WO mood stabilizer
illness - Benzos should not be used as monotherapy
Psychosis: APh
Situational 1/2gAPh OR haloperidol + lorazepam OR BZD
ADHD
Patho Dysfx of DA/NE pathways
1 hallmark: impulsiveness + hyperactivity + inattention
Dx: >6 sx (5 for >17yo) x >6mo and have neg impact AND present in >2 settings
Non-Pharm Less effective at ↓ core sx than stimulants
RESP QUICK LESSON
Obstructive lung disease FEV1/FVC <0.7
Asthma
Patho Severity based on level of tx required to achieve sx control
i. Mild: well controlled w short-acting BD PRN, low dose ICS or LTRA
ii. Mod: well controlled w low dose ICS/LABA
iii. Severe: high dose ICS/LABA
Sx: 12% FEV1 ↑ post-BD
Risk GERD, fam hx, atopic triad
Exacerbations high SABA use, inadeq CS, poor adherence, incorrect technique, comorbs
(obesity, chronic rhinosinusitis, GERD, allergy, preg), exposures (smoking,
allergens), major psych/SE, low lung fx, ever intubated/ICU, >1 severe
exacerbation in last 12mo, FEV1 <60%, high BD rev
Drug NSAIDs/ASA/COX-2, tartrazine, sulfites, BB (unless very well controlled
asthmatic cardioselective: metoprolol, bisoprolol, atenolol)
Nonpharm Avoid precip factors, smoking cess, treat modifiable risk (obesity, anx, depression, GERD, chronic
rhinosinusitis, OSA)
Flu, pneumo vax
Immunotherapy: mb useful for concomitant allergic rhinitis (mod-sev) >5yo
Treatment SABA monotherapy NR all adults/adols should have an ICS-containing regimen
SAMAs: can be used in addition to SABA for acute exacerbations, alt for those susceptible to
tremor/tachy
LAMA: add-on despite mtn
LTRA: add on for mod-sev w ICS, 2nd line mono after daily low-ICS or PRN ICS/LABA, add on to low
dose ICS in concomitant rhinitis
- Can be used >2yo
Adults
Adults: + LABA before ↑ ICS *no LABA monotherapy
Always: PRN low dose ICS-formoterol (other: SABA)
Step 1: PRN low dose ICS-formoterol (max 6inh on one occasion, max 8/day)
- >6yo
Step 2: daily low dose ICS or PRN low dose ICS-formoterol
- LTRA or low dose ICS whenever SABA is taken
Step 3: low dose ICS-LABA
- Med dose ICS or low dose ICS+ LTRA
- LABAs only for pts already taking ICS (mono ↑ death), may be ICS sparing
Step 4: medium dose ICS-LABA
- High dose ICS, add on tiotropium or LTRA
Pediatrics
Pediatrics: ↑ ICS dose before + LABA
Step 1: low dose-ICS whenever SABA is used
Step 2: daily low dose ICS
- LTRA or low-dose ICS when SABA used
Step 3: low dose ICS-LABA or medium dose-ICS
- Low-dose ICS + LTRA
Step 4: medium dose ICS-LABA
- High dose ICS or + tiotropium or + LTRA
Exacerbations
SABA (4-10 puffs) via spacer at ↑ doses q20min, PO pred (25-50mg x 7-14d), ↑ controller med/↑dose x
>2-4wks
- +/- ipratropium
Oxygenation
Monitoring Sx control over past 4 wks
- Daytime asthma sx >2x/wk, reliever needed >2x/wk
- Any nocturnal awakening
- Any activity limitation, missing school/work
- PEF <90% predicted
, Step up: check inhaler technique, adherence, comorbs, exposure to irritants
- Inhaler technique: shake, hold breath 5-10s, if 2nd puff req wait 15-30s
- Spacer: whistling sound indicates breathing that is too fast
Step down: sx controlled for 3mo + low risk of exacerbations
- Ceasing ICS NR
ICS: 4-6 wks
ICS
Dose
ADR Spacer ↓ dysphonia and candidiasis
DI Strong CYP3A4 (except beclomethasone)
COPD
Patho - <12% post-BD FEV1 ↑ (<70%)
- Spiro may improve but never normalize
mMRC
1. Only breathless w strenuous exercise
2. SOB hurrying on level ground, walking up a hill
3. Slower than most
4. Stop for breath after 100m level
5. Too breathless to leave house
Group A: mMRC 1-2 or CAT <10 with 0 or 1 exacerbations in past y (not leading to hospital admit)
Group B: mMRC >3 or CAT >10 with 0 or 1 exacerbations in past y (not leading to hospital admit)
Group C: mMRC 1-2 or CAT <10 with >2 exacerbations in past y (or hospital admit) or >1 in past y
leading to hospital admission
Group D: mMRC >3 or CAT >10 with >2 exacerbations in past y (or hospital admit) or >1 in past year
leading to hospital admission
Acute Exacerbations
Mild: resolved using short-acting BD alone
Mod: use of abx and/or PO CS
Severe: hosp or ER dt underlying resp failure
Risk Smoking, air pollution, long term dust/chemical exposure, A1AT deficiency, >40yo
Drug (exacerbate/mimic): BB, ACEI
Nonpharm Spiro w BD for: smokers >35yo, past smokers w >20 pack year hx, recurrent/chronic resp sx, fam hx
COPD, significant occupational exposure
Flu, pneumo vax
PR programs for groups B-D
Lung resection: improve survival, ↓ hyperinflation, improve exercise capacity
Treatment Address risk factors, self-management, exercise, education
A. BD
B. LABA or LAMA (first line) LAMA + LABA
C. LAMA LAMA + LABA (OR LABA + ICS)
- ICS: may ↓ exacerbation freq, has been assoc w PNA
D. LAMA + LABA + ICS
Acute Exacerbations
Hosp: periph edema/cyanosis, use of accessory inspiratory muscles, comorbid HF
SOB: SABA + SAMA
Severe COPD: pred x 5d wi 30 days of exacerbation
Severe exacerbation + 2 of (↑ sputum purulence OR V, worsening SOB): abx (strep pneumo, H flu, m
, cat)
- Broad spectrum abx sb provided in complicated exacerbations (IHD, FEV <50%, home O2)
- Consider class change if abx in past 3mo
i. <4 exacerbations in past y (haemophilus, m cat, strep pneumo): amox x 5-7d, doxy x
5-7d, SMX/TMP x 5-7d
ii. >4 exacerbations in past y, failure of first agent, abx in past 3mo (+ enterobac,
pseudomonas): amoxclav x 5-10d, cefuroxime x 5-10d, levoflox x 5d, (OR: azithro x
3d, clarithro x 5-10d)
- Gram neg (Klebsiella-advanced age, FEV1 <50%, >4 exacerbations/yr, IHD, home oxygen,
chronic PO CS use): amoxclav or 2g FQ (cipro if high suspicion for pseudomonas)
Allergic Rhinitis
Patho Intermittent: <4d/wk OR <4 consec wks
Persistent: >4d/wk OR >4 consec wks
Mod/severe: impaired activities
Refer <2yo, treatment failure/persistent (non-rx for 2wk), mod-sev, unilat, OM, uncontrolled asthma,
SOB/diff breathing, unilat sx, >40.5 high fever, severe HA/eye pain
Risk Drug: BB, ACEi, chlorpromazine, amitriptyline, ASA/NSAIDs, rebound from topical decongestants, alpha
blockers, oral contraceptives
Nonpharm Avoid allergens, avoid aggravating factors, nasal saline irrigation, lubricant eye drops, cold/warm
compresses
Immunotherapy: for severe diff to control allergic rhinitis and cannot avoid allergen
Using nasal sprays: gently blow nose, shake bottle, occlude one nostril, blow away from septum, rinse tip
w hot water and dry
Treatment Mild sx or <2mo PO AH + PO/IN decongestant
Mod/sev or >2mo IN CS + PRN AH + PO/IN decongestant for B/T + ophth AH /MCS for
conjunctival sx PRN
Rhinorrhea: INCS, anticholinergic, antihistamines most effective
- PO AH, LTRA, Intranasal mast cell stabilizers less effective
Congestion: INCS most effective
- Decongestants, LTRAs, PO AH, ophthalmic mast cell stabilizers less effective
- IN AC not effective at congestion
Nasal itching: INCS (most effective)
- Less effective: INMCS, PO AH, PO LTRA
- Decongestants and INAH not effective
Idiopathic rhinitis: IN anticholinergic + INCS
Agents OTC
PO AH 1gAH NR first line dt ADR
- Chlorpheniramine preferred in preg
DI CYP2D6 inh (amiodarone, celecoxib, bupropion, paroxetine)
- Diphenhydramine may ↑ CYP2D6 substrate (metoprolol, venlafaxine)
2gAH first line for mild allergic rhinitis >2yo
- Most effective if taken px
- Req renal dose adjustment, ↓ doses in liver impairment for loratadine
- Cetirizine and loratadine can still cause some sedation
- Loratadine preferred in preg
↑QT reported w amiodarone
- Fexofenadine dosed BID, avoid Al/Mg antacids
IN mast cell Onset 4-7d
stabilizers
Decongestants PO: avoid use in uncontrolled HTN or hyperthyroid, preg
- Do not use wi 2w of MAOI, ergot derivatives
- Can cause blood sugar changes
- Avoid use in 1T, <6yo
IN: do not use for more than 3-5d
Prescription
INCS First line for mod-sev peak effect in 1-2w (adeq trial 2-4w), give regularly and 1w
before allergen exposure
, - Children: best evidence for mometasone, fluticasone propionate
- preg: best evidence for beclomethasone/budesonide, potential risk w 1T
triamcinolone
beclomethasone does not have OD dosing
Anosmia usually not improved
IN AH >12yo
(levocabastine) If no improvement in 3d, DC (onset 10min)
IN Vasomotor rhinitis titrate dose to response
anticholinergic
LTRA Helpful if concomitant asthma or nasal polyps
Topical When PO AH, INCS, and LTRA do not improve conjunctival sx
ophthalmic AH - Discard cromoglycate wi 1mo
Do not use topical vasoconstrictors
Topical mast Several day onset, q6h intervals to maintain effect (IN)
cell stabilizers
Monitoring Sx improvement/resolution in 1w
Cough
Red Flags Uncontrolled COPD/asthma, CHF, GERD, hazardous chemicals/irritants, >3w, bloody sputum, SOB,
CP, vomiting/choking, acute alteration in mental status, recent 6mo ACEi/BB
PSYCH SHORT LESSON
Acute Agitation
Drug Antichol, CS, amantadine, DA/DA Ag
Opioid tox/withdrawal, BZD withdrawal
Non-Pharm Ensure safety det cause non-pharm measures
Verbal De-esc: respect personal space, do not be provocative, establish verbal contact, concise/simple
language, ID feelings/desires, listen closely, agree/agree to disagree, lay down law/set clear limits, offer
choices/optimism, debrief PT/staff
Pay attention to safety
- Speak in calm env, assist in controlling behavior, reassure they are in safe environment
Limit sedative use in dementia PTs
Pharm Reserve BZDs where sx are attributed to OH/BZD withdrawal
- Choose long half lives
Use ↓ doses of APh in elderly for shortest duration w close monitoring
***do not admin parenteral BZDs w IM olanzapine dt cardiac/resp complications
Delirium 1gAPh (haloperidol, loxapine) OR 2gAPh (olanzapine, risperidone, quetiapine)
- Haloperidol most studied
- Olanzapine and risperidone ODT
- Olanzapine IM
Dementia Only if risk of harm
- Use low doses and cautiously titrate
2gAPh (Risperidone) OR 1gAPh (Avoid in LBD) OR AChEI (LBD) OR memantine OR
trazodone
- Little evidence for quetiapine
- Haloperidol NR
2nd line: BZD (Lorazepam, oxazapem)
Brain Injury BB OR AED (CMZ, VPA) OR APh
- Avoid BZDs
Mental Mania: 2gAPh OR 1gAPh + lorazepam WITH/WO mood stabilizer
illness - Benzos should not be used as monotherapy
Psychosis: APh
Situational 1/2gAPh OR haloperidol + lorazepam OR BZD
ADHD
Patho Dysfx of DA/NE pathways
1 hallmark: impulsiveness + hyperactivity + inattention
Dx: >6 sx (5 for >17yo) x >6mo and have neg impact AND present in >2 settings
Non-Pharm Less effective at ↓ core sx than stimulants
