Description

Raus Respiratory Care Pharmacology 9^th Edition Gardenhire Test Bank

ISBN-13: 978-0323299688

ISBN-10: 0323299687

 

 

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Chapter 16: Selected Agents of Pulmonary Value

Gardenhire: Rau’s Respiratory Care Pharmacology, 9th Edition

 

MULTIPLE CHOICE

 

1. A drug intended for therapy of congenital a₁-antitrypsin deficiency is

a.	pulmozyme.
b.	pneumovax.
c.	prolastin.
d.	prednisone.

 

 

ANS:  C

a₁-proteinase inhibitor (API) is indicated for long-term replacement therapy in individuals with congenital deficiency of API, with clinically demonstrable panacinar emphysema. At the present time, three agents are available: Aralast, Prolastin, and Zemaira. Aralast and Zemaira are indicated only for patients who have established a₁-proteinase deficiency. Pulmozyme (dornase alfa) is a mucolytic, Pneumovax is a vaccine, and prednisone is a steroid. Although these drugs may be helpful at some point in the disease process, they do not specifically treat a₁-antitrypsin deficiency.

 

REF:   p. 275

 

2. The physician suspects that your patient may have a₁-antitrypsin (a-AT) deficiency. Which disease process would help to confirm this diagnosis?

a.	Panacinar emphysema
b.	Centrilobular emphysema
c.	Bronchiectasis
d.	Asthma

 

 

ANS:  A

a-AT deficiency is a genetic defect that can lead to the development of severe panacinar emphysema. In about 50% of cases of emphysema that result from a₁-proteinase inhibitor (API) deficiency, there is accompanying chronic bronchitis with mucus hypersecretion, perhaps as a result of secretory cell metaplasia caused unchecked proteases in the epithelial lining fluid.

 

REF:   p. 275

 

3. Emphysema is a process of

a.	excessive mucus secretion.
b.	large airway dilation.
c.	bronchial smooth muscle constriction.
d.	alveolar wall destruction.

 

 

ANS:  D

The pathogenesis of emphysema is described as a process of alveolar wall destruction caused insufficient protection from the protease neutrophil elastase, an enzyme that can cleave all forms of connective tissue and degrade elastic fiber in the lungs solubilizing elastin. With inadequate a₁-proteinase inhibitor (API) levels in the lung to balance the protease activity, emphysema results at a significantly earlier age than is normally seen.

 

REF:   p. 275

 

4. The major limitation of Prolastin therapy is

a.	lack of availability.
b.	cost.
c.	no FDA approval.
d.	severe adverse effects.

 

 

ANS:  B

Prolastin is extremely expensive, with therapy costing $25,000 to $40,000 per year. A cost-effectiveness analysis of Prolastin concluded that a₁-antitrypsin (a₁-AT) replacement therapy is cost-effective in individuals who have severe a₁-AT deficiency and severe chronic obstructive pulmonary disease (COPD). The American Thoracic Society stated that a₁-proteinase inhibitor (API) augmentation therapy should be used for patients with a serum concentration of API less than 11 µmol/L, or 80 mg/dl.

 

REF:   p. 276

 

5. The recommended dosage of Prolastin is

a.	30 mg/kg once daily.
b.	40 mg/kg once weekly.
c.	50 mg/kg once weekly.
d.	60 mg/kg once weekly.

 

 

ANS:  D

The recommended dosage of a₁-proteinase inhibitor (API) is 60 mg/kg body weight, given once weekly. The dose is given intravenously at a rate of 0.08 ml/kg/min or greater, depending on patient comfort, and usually takes about 15 to 30 minutes for total infusion.

 

REF:   p. 276

 

6. An 80-kg man should receive what dose of Prolastin?

a.	2400 mg weekly
b.	480 mg daily
c.	4800 mg weekly
d.	240 mg daily

 

 

ANS:  C

The recommended dosage of a₁-proteinase inhibitor (API) is 60 mg/kg body weight, given once weekly. The dose is given intravenously at a rate of 0.08 ml/kg/min or greater, depending on patient comfort, and usually takes about 15 to 30 minutes for total infusion.

60 mg/kg × 80 kg = 4800 mg/weekly

 

REF:   p. 276

 

7. Potential adverse effects of Prolastin administration include which of the following?
8. Hypertension
9. Fever
10. Arrhythmias
11. Exacerbation
12. Flulike symptoms

 

a.	1 and 3 only
b.	2, 4, and 5 only
c.	1, 2, and 4 only
d.	1, 2, 3, 4, and 5

 

 

ANS:  B

Because a₁-proteinase inhibitor (API) agents are derived from human plasma, there is a risk of disease transmission. Although there was some variation in reactions to each API agent, fever, exacerbation, and flulike symptoms were most common.

 

REF:   p. 276

 

8. Physical symptoms of nicotine withdrawal include which of the following?
9. Irritability
10. Weight gain
11. Craving for nicotine
12. Anxiety
13. Sleep disturbances

 

a.	3 only
b.	1, 2, and 4 only
c.	2, 3, and 5 only
d.	1, 2, 3, 4, and 5

 

 

ANS:  D

Withdrawal from the nicotine in tobacco products is difficult because the stimulatory and reward effects are lost, and physical symptoms occur. The latter include craving for nicotine, nervousness, irritability, anxiety, drowsiness, sleep disturbance, impaired concentration, and increased appetite with attendant weight gain.

 

REF:   p. 276 | p. 277

 

9. Nicotine replacement agents are indicated to

a.	simulate the act of smoking.
b.	relieve nicotine withdrawal symptoms.
c.	punish negative behaviors.
d.	produce strong adverse effects of smoking.

 

 

ANS:  B

Nicotine replacement agents are indicated as an aid to smoking cessation to relieve nicotine withdrawal symptoms; nicotine replacement therapy, in various dosing formulations, is intended to aid with smoking cessation allowing initial replacement and then gradual withdrawal of the nicotine found in tobacco. Replacement therapy should be used as part of a comprehensive smoking cessation program to increase compliance and reduce relapse.

 

REF:   p. 278

 

10. Bupropion is an

a.	anxiolytic.
b.	antidepressant.
c.	anticholinergic.
d.	antibiotic.

 

 

ANS:  B

Smoking cessation drug therapy includes various formulations of nicotine and bupropion, an antidepressant found to be useful as an aid to smoking cessation. Zyban, which is used for smoking cessation and not indicated for depression, contains the same ingredients as Wellbutrin.

 

REF:   p. 278 | p. 279

 

11. Smoking cessation drugs are available in which of the following forms?
12. Gum
13. Nasal spray
14. Transdermal patch
15. Intravenous infusion
16. Tablets

 

a.	1 and 3 only
b.	2, 3, and 5 only
c.	1, 2, 3, and 5 only
d.	1, 2, 3, 4, and 5

 

 

ANS:  C

Nicotine polacrilex, a resin complex, is available as a chewing gum, as a lozenge, as a nasal spray, and as an inhaler. The nicotine transdermal system is a multilayered unit that delivers nicotine for 24 hours after application to the skin. Bupropion (Zyban) is available in 150-mg sustained-release tablets.

 

REF:   p. 278 | p. 279

 

12. The nicotine replacement method that provides the most consistent level of nicotine and that is easy and convenient is

a.	the transdermal patch.
b.	gum.
c.	a nasal spray.
d.	an inhaler.

 

 

ANS:  A

The nicotine transdermal system is a multilayered unit that delivers nicotine for 24 hours after application to the skin. The transdermal product provides a more consistent level of nicotine than the gum or lozenge. This is an easy, convenient, and inconspicuous method of nicotine replacement delivery.

 

REF:   p. 278

 

13. Zyban is a(n)

a.	nicotine replacement.
b.	bronchodilator.
c.	antidepressant.
d.	steroid.

 

 

ANS:  C

Bupropion is an antidepressant found in Wellbutrin; it is also a nonnicotine aid to smoking cessation. The drug is a relatively weak inhibitor of neuronal uptake of norepinephrine, serotonin, and dopamine, which is the basis for its antidepressant effect. The exact mechanism which bupropion aids in smoking cessation is unknown. Bupropion may relieve nicotine withdrawal slowing the normal reuptake of dopamine or preventing its breakdown in the central nervous system. It has been shown that mood and emotional state are related to the need for smoking and nicotine, although bupropion is effective in smoking cessation even if the smoker is not depressed.

 

REF:   p. 279

 

14. Nitric oxide (NO) is a

a.	cardiac stimulant.
b.	pulmonary vasodilator.
c.	pulmonary vasoconstrictor.
d.	systemic vasodilator.

 

 

ANS:  B

NO is a product of endothelial cells that acts as a nitrovasodilator. Because NO diffuses so readily into the bloodstream and is inactivated being bound to hemoglobin, its action is limited to the pulmonary vascular endothelium, whether generated endogenously within the lung or inhaled as an exogenous gas. It is a selective pulmonary vasodilator. NO was investigated for its ability to reduce pulmonary vascular resistance in various disease states, such as persistent pulmonary hypertension of the newborn (PPHN) and acute respiratory distress syndrome (ARDS). NO is approved for use in neonates with hypoxic respiratory failure, to reduce pulmonary artery pressure, and to increase oxygenation in newborns with pulmonary hypertension and hypoxia.

 

REF:   p. 280

 

15. The recommended dose of nitric oxide (NO) is

a.	20 ppm.
b.	30 ppm.
c.	40 ppm.
d.	60 ppm.

 

 

ANS:  A

NO, supplied in two sizes of gas cylinder, is available at 100 ppm and 800 ppm. The recommended dose is 20 ppm. The treatment should be maintained up to 14 days, or until the underlying oxygenation problem has resolved and the neonate can be successfully weaned from NO. In the Neonatal Inhaled Nitric Oxide Study (NINOS), most patients who failed to improve on 20 ppm and whose dose was increased to 80 ppm had no response at the higher concentration. The risk of methemoglobinemia and elevated nitrogen dioxide (NO₂) levels increases significantly at doses greater than 20 ppm.

 

REF:   p. 281

 

16. The drug used to treat hypoxic respiratory failure in newborns with pulmonary hypertension is

a.	ribavirin.
b.	Xopenex.
c.	Survanta.
d.	nitric oxide.

 

 

ANS:  D

Nitric oxide (INOmax) is used in conjunction with ventilatory support and other critical care in the treatment of term and near-term (=34 weeks) neonates with hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension. Ribavirin is an antiviral medication. Xopenex is a trade name for the bronchodilator levalbuterol and Survanta is an exogenous surfactant given to neonates to prevent or treat respiratory distress syndrome.

 

REF:   p. 281

 

17. Which of the following is the enzyme that is responsible for cleaving good lung tissue in a₁-antitrypsin deficiency?

a.	Prolastin
b.	Neutrophil elastase
c.	Leukocyte protease inhibitor
d.	Zemaira

 

 

ANS:  B

The pathogenesis of emphysema is described as a process of alveolar wall destruction caused insufficient protection from the protease neutrophil elastase, an enzyme that can cleave all forms of connective tissue and degrade elastic fiber in the lungs solubilizing elastin. The main role of another protease inhibitor, secretory leukocyte protease inhibitor (SLPI), which is secreted bronchial glands and goblet cells, is to protect the airway epithelium against proteolytic injury. Zemaira is an agent used to slow the progression of the disease process itself.

 

REF:   p. 275

 

18. ___________ is not used pharmacologically to treat smoking addiction.

a.	Nicotine replacement patch
b.	Varenicline (Chantix)
c.	Bupropion (Zyban)
d.	Prolastin

 

 

ANS:  D

The nicotine transdermal system is a multilayered unit that delivers nicotine for 24 hours after application to the skin. Bupropion is an antidepressant found in Wellbutrin; it is also a nonnicotine aid to smoking cessation. Varenicline (Chantix) is a selective a₄b₂ nicotinic acetylcholine receptor partial agonist developed for explicit use in smoking cessation. Prolastin is indicated only for patients who have established a₁-proteinase deficiency.

 

REF:   p. 278 | p. 279

 

19. Nitric oxide (NO) should not be used in neonates with

a.	left-to-right shunts.
b.	pulmonary hypertension.
c.	right-to-left shunts.
d.	increased pulmonary artery pressure.

 

 

ANS:  C

NO should not be used in neonates who are known to be dependent on right-to-left shunt. Dilation of the pulmonary vasculature would lower the pressure in the right heart and possibly cause the shunt to reverse. If the patient is dependent on such a shunt for survival, death may result. A left-to-right shunt would not be reversed pulmonary vasodilation because lowering the pressures in the right heart would only increase the shunt. The purpose of NO is to relieve pulmonary hypertension.

 

REF:   p. 283

 

20. Prolastin is

a.	a corticosteroid.
b.	an antihistamine.
c.	an a1-proteinase inhibitor.
d.	a bronchodilator.

 

 

ANS:  C

a₁-proteinase inhibitor (API) is indicated for long-term replacement therapy in individuals with congenital deficiency of API, with clinically demonstrable panacinar emphysema. At the present time, three agents are available: Aralast, Prolastin, and Zemaira. Aralast and Zemaira are indicated only for patients who have established a₁-proteinase deficiency. Prolastin is not indicated for use in patients other than individuals with the PI*ZZ, PI*Z-null, or PI*null-null phenotype.

 

REF:   p. 276

 

21. Ventavis is indicated for
22. pulmonary arterial hypertension.
23. type 1 diabetes mellitus.
24. type 2 diabetes mellitus.
25. a₁-antitrypsin deficiency.
26. smoking cessation.

 

a.	1 only
b.	2, 3, and 5 only
c.	2 and 3 only
d.	4 only

 

 

ANS:  A

Iloprost (Ventavis) is a synthetic analogue of prostacyclin (PGI₂). The drug is made available as an inhalation solution that is delivered via one of two novel aerosol delivery devices, either the I-neb AAD (adaptive aerosol delivery) system or the Prodose AAD system. Ventavis dilates systemic and pulmonary arterial vascular beds. Ventavis is indicated for the treatment of pulmonary arterial hypertension in patients with New York Heart Association (NYHA) class III or IV symptoms.

 

REF:   p. 283

 

22. Toxic products of nitric oxide (NO) include
23. nitrogen dioxide.
24. formation of methemoglobin.
25. type 2 diabetes mellitus.
26. a₁-antitrypsin deficiency.

 

a.	1 and 2 only
b.	2 and 3 only
c.	2 and 3 only
d.	4 only

 

 

ANS:  A

Toxicity with exposure to NO can be caused NO itself or the formation of the nitrite, nitrogen dioxide, and methemoglobin.

 

REF:   p. 282 | p. 283

 

23. Individuals attempting to quit smoking using Nicotrol should be advised

a.	If taken while using tobacco products, potential toxic concentrations of nicotine can occur in the blood.
b.	Bupropion has a better quit rate compared with Chantix.
c.	The treatment process lasts 3 weeks.
d.	Nortriptyline is another smoking cessation option approved the FDA for individuals who fail to quit smoking with Chantix.

 

 

ANS:  A

Individuals receiving nicotine replacement therapy should be informed that the replacement formulations contain active nicotine. If these replacement formulations are taken while still using tobacco products, potentially toxic concentrations of nicotine can occur in the blood. Individuals should stop smoking when initiating therapy. Transference of nicotine dependency from the tobacco product to the replacement product can occur. Use within a program of smoking cessation is encouraged to achieve complete withdrawal. In clinical trials, varenicline (Chantix) produced a 39% quit rate compared with 20% for bupropion and 11% for placebo after 12 weeks. In another study, Chantix produced quit rates of 44% and 49% at lower and higher doses of the drug compared with placebo at 12%. Chantix is administered in a 12-week-long treatment process that begins with a 1-week titration process. Nortriptyline is a tricyclic antidepressant approved the U.S. Food and Drug Administration (FDA) to treat depression. It is not approved the FDA for use as a smoking cessation aid; however, similar to bupropion, it is thought to have an effect on tobacco dependence because of its antidepressant mode of action.

 

REF:   p. 279 | p. 280

 

24. A smoker with very low dependency seeks your advice about smoking cessation. What nicotine replacement agent would you suggest?

a.	Nicotine replacement patch (21 mg)
b.	Varenicline (Chantix)
c.	Nicotine inhaler
d.	Bupropion

 

 

ANS:  C

The nicotine inhaler offers smokers a “simulated cigarette”; the kit contains a 10-mg/cartridge unit dose, which delivers 4 mg/use, a mouthpiece, blister trays of nicotine cartridges, and a plastic case. The use of a mouthpiece resembling a cigarette holder allows delivery of the nicotine in a manner similar to smoking a cigarette, with oral gratification. This system delivers less nicotine than the other systems. All of the nicotine is absorbed across the oropharyngeal membranes. The inhaler may be most useful in the low-dependency smoker, as an adjunct to the patch to treat sudden cravings, or in combination with bupropion.

 

REF:   p. 279 | p. 280

 

25. Respiratory care assessment of smoking cessation drug therapy includes
26. monitoring abstinence rates at intervals such as 3, 6, or 12 months.
27. monitoring for symptoms of nicotine overdose.
28. counseling and support throughout treatment for smoking cessation.
29. assessing patients for weight gain and encouraging an exercise program.

 

a.	1 and 2 only
b.	2 and 3 only
c.	1, 2, and 3 only
d.	1, 2, 3, and 4

 

 

ANS:  D

The primary outcome of interest with smoking cessation drug therapy is success in quitting over the long-term.

• Monitor abstinence rates at intervals such as 3, 6, or 12 months.
• Monitor for symptoms of nicotine overdosage (possible if subjects continue smoking while using nicotine substitutes), such as nausea, salivation, abdominal pain, vomiting, diarrhea, cold sweat, headache, dizziness, disturbed vision and hearing, mental confusion, or marked weakness.
• Assess bupropion use for improvement in emotional attitude, including reduction in irritability, anxiety, difficulty in concentrating, or depression.
• Assess varenicline use for improvement in nicotine withdrawal symptoms.
• Assess clonidine and nortriptyline for possible use as smoking cessation aids.
• Monitor clonidine for adverse actions related to cardiovascular status.
• Monitor nortriptyline for change in emotional state.
• Assess patients for weight gain, and encourage an exercise program to prevent relapse caused desire for appetite control.
• Continue to provide counseling and support throughout treatment for smoking cessation.

 

REF:   p. 283 | p. 284

 

26. The two inhaled prostacyclin analogues available in the United States are

a.	Iloprost and Tyvaso.
b.	Varenicline and bupropion.
c.	Albuterol and Atrovent.
d.	Xopenex and Survanta.

 

 

ANS:  A

Iloprost is an inhaled prostacyclin available in the United States. Tyvaso is an inhaled prostacyclin vasodilator used for the treatment of pulmonary hypertension. Albuterol is a sympathomimetic bronchodilator. Atrovent is the trade name for ipratropium bromide, an anticholinergic bronchodilator. Xopenex is a trade name for the bronchodilator levalbuterol, and Survanta is an exogenous surfactant given to neonates to prevent or treat respiratory distress syndrome. Varenicline is a selective a₄b₂ nicotinic acetylcholine receptor partial agonist developed for explicit use in smoking cessation. Bupropion, an antidepressant, and Varenicline have been found to be helpful in smoking cessation.

 

REF:   p. 278

 

27. Signs of strong physical addiction to nicotine include
28. inhaling smoke frequently and deeply.
29. smokes even when ill enough to be bed-ridden.
30. can smoke less than 10 cigarettes a day if in a smoke-free environment.
31. smokes within 30 minutes of waking up.

 

a.	1 and 2 only
b.	2 and 3 only
c.	1, 2, and 4 only
d.	1, 2, 3, and 4

 

 

ANS:  C

Signs of strong physical addiction or dependence on nicotine

• Smokes more than 15 cigarettes per day
• Prefers brands with nicotine levels above 0.9 mg
• Has a habit of inhaling smoke frequently and deeply
• Smokes within 30 minutes of rising
• Finds it difficult to give up the first morning cigarette and smokes more frequently in the morning
• Finds it difficult to refrain from smoking in smoke-free environments
• Smokes even when ill enough to be bed-ridden