Patient Cases - Pulm Pharm

BP is a 66-year-old woman who underwent a two-vessel coronary artery bypass graft 8 days ago and has been on a ventilator in the surgical intensive care unit since then. Her temperature is now rising and her chest radiograph reveals a new infiltrate in the right lower lobe. Her medical history includes coronary artery disease with a myocardial infarction 2 years ago, COPD, and hypertension. All antipseudomonal antibiotics in the institution are active against at least 90% of strains. BP has no known drug allergies. Which is the best empiric therapy for BP? ​

Cefepime 2 g IV every 8 hours plus tobramycin 7 mg/kg IV every 24 hours plus vancomycin 15 mg/kg IV every 24 hours

A 64-year-old woman with COPD in GOLD patient group A presents for a clinic visit. In the past few days, she has had a worsening of shortness of breath and a productive cough with more "cloudy" and more copious sputum than usual. Pulse oximetry is 95% on room air. She has a nebulizer at home. In addition to regular use of albuterol plus ipratropium by nebulizer every 1 to 4 hours, which is the best course of action? ​

Add oral prednisone 40 mg once daily for 5 days and azithromycin 500 mg daily for 3 days

Which of the following would be safe to use in a patient with a severe allergy to penicillins (anaphylaxis)?

Aztreonam

A 23-year-old woman has been coughing and wheezing about x3/weekly, and she wakes up at night about x3/month. She has never been given a diagnosis of asthma and has not been to a physician "in years." She uses her roommate's albuterol inhaler when she's wheezing, about x3/weekly, but having recently run out of refills, she is seeking care. Her activities are not limited by her symptoms. Spirometry today reveals FEV1 82% of predicted. At first, the patient's symptoms were well controlled on your recommended therapy. However, when winter arrive, her symptoms were no longer well controlled, and she started using her controller 3 or 4 days/week during the day. Which is the preferred treatment change?

Budesonide/formoterol MDI 80/4.5 mcg per puff 2 puffs twice daily (320 mcg/day)

At first, the patient's symptoms were well controlled on your recommended therapy. However, when winter arrived, her symptoms were no longer well controlled, and she started using her reliever 3 or 4 days per week during the day. Which is the preferred treatment change? ​

Budesonide/formoterol MDI 80/4.5 mcg per puff 2 puffs twice daily (320 mcg/day).

Which of the following drugs for smoking cessation should not be used for a patient with a past medical history of seizures?

Bupropion SR (Zyban)

Which of the following best matches the mechanism of action for the antitussive dextromethorphan (Delsym, Robitussin)?

Decreases the sensitivity of cough receptors by depressing the medullary cough center.

PE is a 56-year-old man who comes to the clinic with a 3-day history of fever, chills, pleuritic chest pain, malaise, and productive cough. In the clinic, his temperature is 102.1°F (38.9°C) (all other vital signs are normal). His CXR reveals consolidation in the right lower lobe. His white blood cell count (WBC) is 14,400 cells/mm3 (high), but all other laboratory values are normal. He is given a diagnosis of community-acquired pneumonia (CAP). He has not received any antibiotics in 5 years and has no chronic disease states. He is allergic to sulfa drugs.​ Which is the best empiric antibiotic regimen and duration for PE? ​

Doxycycline 100 mg orally twice daily for 5 days​

A 62-year-old man was recently given a diagnosis of COPD. Spirometry reveals an FEV1/FVC 60% of predicted. His symptoms are quite bothersome. He reports walking more slowly than others because of shortness of breath and having to stop to catch his breath every so often when walking on level ground (CAT score 11). He had 1 exacerbation in the past year that did not require hospitalization. Which is the most appropriate patient group classification for him, according to the GOLD guidelines? ​

GOLD 2, Group B​

A 25-year-old man presents to the ED with shortness of breath at rest. He is having trouble with conversation. He used 4 puffs of albuterol MDI at home, with no resolution of symptoms. His FEV1 is 38% of predicted. Which therapy, in addition to oxygen, is best for him initially in the ED? ​

Give albuterol plus ipratropium by nebulizer every 20 minutes for 1 hour, plus oral prednisone 40 mg daily.

When treating patients with longer durations of systemic corticosteroids for ARDS, which adverse effects of steroids can be avoided by tapering steroids off instead of stopping them abruptly?

HPA-axis suppression

Which of the following is an adverse effect of the CFTR modulator ivacaftor that should be monitored every 3 months for the first year, and then annually thereafter?

Hepatotoxicity (monitor LFTs)

Which is an important side effect of neuraminidase inhibitors should be mentioned to parents before prescribing to children?

Neuropsychiatric events

A 23-year-old woman has been coughing and wheezing about three times weekly, and she wakes up at night about three times per month. She has never been given a diagnosis of asthma and has not been to a physician "in years." She uses her roommate's albuterol inhaler when she's wheezing, about three times weekly, but having recently run out of refills, she is seeking care. Her activities are not limited by her symptoms. Spirometry today reveals FEV1 82% of predicted. Which medication is best to recommend for her, in addition to budesonide/formoterol MDI every 4-6 hours as needed? ​

No additional therapy needed. ​

LC is a 6-year-old male who presents with his mom to the clinic with a 24h history of fever and fatigue and decreased oral intake. He weighs 20 kg and has a history of asthma. He tests positive on a rapid screen in the clinic for Influenza A Virus. ​ Which would be the best first-line therapy to initiate for LC today?

Oseltamivir (Tamiflu) 45 mg PO BID for 5 days​

LC's mother is concerned about her other son who is 8 years old with a history of leukemia, and lives in the same home. He weighs 30 kg. ​ Which option would be best to provide for prophylaxis for LC's brother?​

Oseltamivir 60 mg PO daily for 7 days

Which of the following nicotine replacement therapy options for smoking cessation is long-acting and provides steady blood levels of nicotine?

Patch

Which best matches the mechanism of action of Dornase Alfa (DNase, Pulmozyme)?

Selectively cleaves DNA, thus reducing mucous viscosity.

Which of the following drug/device combos is formulated to release a soft most and provides consistent drug delivery?

Spiriva Respimat

Which of the following is an important adverse effect to monitor for in patients taking Linezolid (Zyvox)?

Thrombocytopenia (monitor platelets)

A 62-year-old man was recently given a diagnosis of COPD. Spirometry reveals an FEV1/FVC 60% of predicted. His symptoms are quite bothersome. He reports walking more slowly than others because of shortness of breath and having to stop to catch his breath every so often when walking on level ground (CAT score 11). He had 1 exacerbation in the past year that did not require hospitalization. ​ In addition to albuterol 2 puffs every 4-6 hours as needed, which pharmacotherapy option is most appropriate to initiate? ​

Tiotropium 2.5 mcg 2 puffs once daily ​