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Summary Key Points for PEBC Exam
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Key point lessons on every therapeutic area covered on the PEBC exam. Includes non-therapeutic information required for success on the PEBC MCQ exam. Note package associated with a 100% first attempt pass rate.

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  • July 23, 2021
  • 88
  • 2020/2021
  • Summary

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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

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