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bnf 2021 > 3. Asthma > Flashcards

3. Asthma Flashcards

1
Q

Medical emergency in Community

Respiratory

A

Acute asthma

Anaphylaxis

Severe Croup

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2
Q

What is asthma

A

Asthma is caused by swelling (inflammation) of the breathing tubes that carry air in and out of the lungs. This makes the tubes highly sensitive, so they temporarily narrow. It may occur randomly or after exposure to a trigger.

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3
Q

Asthma

Symptoms

A

wheezing (a whistling sound when breathing)

breathlessness

a tight chest – it may feel like a band is tightening around it

coughing at night & early morning

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4
Q

Asthma

Step 1

A

REGULAR PREVENTERS

Low dose ICS
Start at BD then OD if good control

Memetasone
Fluticasone
Beclomethasone 
Budesonide 
Ciclesonide

ALTERNATIVELY

🟢 leukotriene receptor antagonist 
(Montelukast) 
🟢theophylline 
🟢inhaled sodium cromoglicate
🟢inhaled nedocromil
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5
Q

Give a drug name

leukotriene receptor antagonist

A

Montelukast

To be taken ON

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6
Q

Montelukast

MHRA warning on SE

A

Can cause:

neuropsychiatric reactions

sleep disturbances,
depression and agitation (1 in 100)

disturbances of attention /memory (up to 1 in 1,000)

very rarely, hallucinations and suicidal behaviour (up to 1 in 10,000 people).

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7
Q

ICS

SE

A

Headache;
oral candidiasis;
pneumonia (in patients with COPD); taste altered;
voice alteration

Uncommon
Anxiety; 
bronchospasm paradoxical; 
cataract; 
vision blurredpp
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8
Q

Asthma

Step 2

A

ADD to initial Tx (low dose ICS)

LABA:
Formoterol
Salmeterol

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9
Q

LABA

SE

A

Arrhythmias; cardiovascular disease; diabetes (risk of hyperglycaemia and ketoacidosis, especially with intravenous use); hypertension; hyperthyroidism; hypokalaemia; susceptibility to QT-interval prolongation

Cautions, further information

Hypokalaemia

Potentially serious hypokalaemia may result from beta2 agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, diuretics, and by hypoxia.

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10
Q

Asthma

Step 3

A

A) LABA not effective: STOP and increase dose ICS

B) LABA effective but asthma not adequately controlled : continue LABA & increase ICS to medium

C) LABA effective but asthma not controlled adequately: continue LABA and trial:

Montelukast (LTRA)
Or 
Toitropium (LAMA) 
Or 
SR theophylline
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11
Q

Asthma

Step 4

A

Persistent poor control

ADD:

A) Oral drug:

Montelukast
SR theophylline
MR beta2 agonist (bambuterol)
Tiotropium bromide

B) ⬆️ dose ICS + spacer
2000mcg beclomethasone or equivalent

Still no control?
Specialist

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12
Q

Asthma

Step 5

A

ADD

Regular oral
Corticosteroids: prednisolone OM
Continue taking ⬆️dose ICS

Specialist referral if still poor control

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13
Q

What do

beta 2 agonists do

List a few

A

Bronchodilators of the bronchi

salbutamol
salmeterol
formoterol
vilanterol

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14
Q

Difference between

salmeterol

And

salbutamol

A

duration of action.

Salmeterol lasts 12 hours LABA

salbutamol lasts about 4–6 hours SABA

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15
Q

Salbutamol
(blue inhaler)

A SA bronchodilator, reliever

Usual dosage ?

A

Up to QDS prn

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16
Q

SABA

Short Acting beta2 agonist

Name 2

A

Salbutamol

Or

Terbutaline

Onset 5mints
Duration:4-6hrs

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17
Q

When to refer pt to Gp if no relief on a SABA

How many hours?

A

If SABA fails to relief for atleast 3 hours

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18
Q

LABA

Long Acting Beta-2 agonists

List

ASTHMA

A

Salmeterol
Formoterol

Most common used in asthma

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19
Q

LABA

Long Acting Beta-2 agonists

List

COPD

A

Formoterol

Indacaterol

Olodaterol

Vilanterol

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20
Q

SABA
&
LABA

SE

A

Arrhythmias; headache; hypokalaemia (with high doses); muscle spasms; nasopharyngitis; nausea; palpitations; rash; tremor

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21
Q

SABA

monitoring

A

In severe asthma, plasma-potassium concentration should be monitored (risk of hypokalaemia).

In patients with diabetes, monitor blood glucose (risk of hyperglycaemia and ketoacidosis, especially when beta2 agonist given intravenously).

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22
Q

Long Acting Muscarinic Antagonist (LAMA)

List

A

Tiotropium OD

Glycopyrronium bromide OD

Aclidnium BD

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23
Q

LAMA

SE

A

Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea, blurred vision, glaucoma

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24
Q

Short Acting Muscarinic Antagonist (SAMA)

List

A

Ipratropium

Asthma & COPD

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25
Q

SAMA

DURATION

A

Onset: within 20 mints

Duration 4 hrs

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26
Q

SAMA

SE

A

Most common

Dry mouth 💋

Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea

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27
Q

Bambuterol

Indication

A

Long acting bronchi dilator

Used in asthma step 4

To be taken ON

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28
Q

LABA + ICS

Not to be used :

A

Alone

In rapidly deteriorating asthma

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29
Q

Best to be used in nocturnal asthma

A

LABA

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30
Q

Inhalers containing

Formoterol therefore can be used as a reliever

(4)

A

Fostair

DuoResp

Spiromax

Symbicort

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31
Q

LABA
SABA

Can cause cardiovascular events therefore what has to told to pt or on RX

A

The dose frequency

And MAX dose puffs in 24hrs

32
Q

Usually when hyperglycaemia is present ….. is also present

A

HypOkalaemia

33
Q

Hypoxia can cause

A

HypOkalaemia

34
Q

HypOkalaemia

Symptoms

A

Weakness and Fatigue.

Muscle Cramps and Spasms
Muscle cramps are sudden
contractions of the muscles
Digestive Problems
Heart Palpitations
Muscle Aches and Stiffness
Tingling and Numbness
Breathing Difficulties
Mood Changes
35
Q

Most common

ICS

List & dosing

A

Beclometasone
Budesonide
Fluticasone
All Taken BD

Except

Ciclesonide OD

Mometasone BD or OD

36
Q

ICS

How do they work

A

Preventers

Take 3-4 weeks to work

37
Q

Beclometasone available
As DRY powder inhaler (DPI)

Brands include:

A

Pulvernal

Beclometasone easy haler

38
Q

Beclometasone available as
CFC-free inhalers

Must be prescribed by brand name sue to potency

List both

A

QVAR is twice as potent as

Clenil Modulite

39
Q

Potency of inhalers

Put them in Oder of most potent :

QVAR
Fostair
CFC containing beclometasone inhalers
Clenil module

A
  1. Fostair
  2. QVAR
  3. Clenil module
  4. CFC containing beclometasone inhalers
40
Q

Minimum age

For

Beclometasone easyhaler

A

18+

41
Q

Minimum age

For

QVAR

A

12 +

42
Q

Minimum age

For

High dose Clenil Modulite 200 or 250

A

12+

43
Q

An indication of incorrect inhalation technique

List 2

A

Hoarse voice

Sore throat

Oral thrush

44
Q

What is

Oropharyngeal deposition

A

Drugs in mouth or back of throat due to poor inhalation technique

45
Q

NICE recommends

Using a spacer with pressurised metered dose inhalers
for patients under…… years.

A

15

46
Q

What is

Paradoxical bronchospasm

And they can be caused by what?

A

Paradoxical bronchospasm is the unexpected constriction of smooth muscle walls of the bronchi that occurs in the setting of an expected bronchodilatory response

ICS

It it does happen, stop and use alternative

47
Q

Mild

(Paradoxical)bronchospasm

Can be avoided by:

A

By using SABA before an ICS

Transferring from pMDI to a dry powder inhaler

48
Q

Smoking and ICS

increase or decrease dose?

A

Increase dose

49
Q

Do patients on ICS need a steroid card?

A

Only if they are on HIGH doses; especially those on unlicensed high doses

50
Q

Leukotriene receptor antagonists

Montelukast
Or
Zafirlukast

Indication

Withdrawal side effect with on Corticosteroids

A

Chronic asthma

Systematic relief of hayfever in asthma

SE: churg strauss syndrome

51
Q

What is

Churg strauss syndrome

A

Churg-Strauss syndrome
is a disease characterized by inflammation of the blood vessels.

Churg-Strauss syndrome occurs in patients with a history of asthma or allergy.

Symptoms of Churg-Strauss syndrome include fatigue, weight loss, nasal passage inflammation, numbness, and weakness

It occurs on withdrawal or reduction of an concomitant ORAL corticosteroids

52
Q

Zafirlukast

SE

A

Hepatotoxic

Pts have to report symptoms of liver toxicity

Abdominal Pain, itch, N+V, jaundice

53
Q

What is theophylline

Given to who?

A

Antimuscarinic

Xanthine bronchodilator

Acute and chronic asthma

Chronic COPD

54
Q

What are the ingredients in

Aminophylline

A

Theophylline
+
Ethylenediamine

Given by injection as it’s 20 x more soluble give IV

Not given IM as it’s irritating: AVOID

55
Q

Therapeutic range

Of theophylline

A

10-20m/L (55-110 mmol/L)

Sample 4-6hrs after dose

56
Q

Theophylline

Warning signs

(Report STAT to dr)

A

Toxicity

(Vomiting, dilated puplis,arrhythmia, restless, agitation, hyperglycaemia)

Symptoms of uncontrolled asthma
(Cough,wheeze,tight chest)

Frequent courses of antibiotics and corticosteroids
(Shows poor asthma control)

57
Q

Theophylline

Pregnancy

A

Benefit outweighs risk

Continue taking as normal with monitoring

58
Q

Theophylline

Branding

A

MR preps have to be prescribed as brand

as different brands have different bioavailability

(If brand not specified contact prescriber)

59
Q

Theophylline

Monitoring

2

A

Potassium

Theophylline concentration

60
Q

Normal potassium level

A

3.5 and 5.5mmol/L

In healthy patients

61
Q

Theophylline

Cautions

A

Cardiac arrhythmias or other cardiac disease; elderly (increased plasma-theophylline concentration) (in adults); epilepsy; fever; hypertension; peptic ulcer; risk of hypokalaemia; thyroid disorder

62
Q

Theophylline

SE

A

Anxiety; arrhythmias; diarrhoea; dizziness; gastrointestinal discomfort; gastrooesophageal reflux disease; headache; hyperuricaemia; nausea; palpitations; seizure; skin reactions; sleep disorders; tremor; urinary disorders; vomiting

Side-effects, further information

Potentially serious hypokalaemia may result from beta2-agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, and diuretics, and by hypoxia. Plasma-potassium concentration should therefore be monitored in severe asthma.

63
Q

Severe asthma

Theophylline

A

Monitoring potassium level is essential!

Major SE hypokalaemia

64
Q

Theophylline

Medicine causing

Increased plasma concentration

7

A

Diltiazem

Verapamil

Cimetidine

Ciprofloxacin

Erythromycin

Clarithromycin

Fluvoxamine

Oestrogen

65
Q

Theophylline

Conditions that cause increase plasma concentration of theophylline 4

A

Elderly

HF

Viral infection

Hepatic impairment

Enzyme inhibitors

66
Q

Theophylline

Reduce plasma concentration

8

A 
Alcohol 
Smoking 
Enzyme inducers 
Carbamazepine 
Primidone
Phenobarbital 
Phenytoin 
Ritonavir
67
Q

Theophylline

And

smoking

A

Decreases theophylline concentration

Dose adjustment may be necessary

Inform dr if you want to start or stop smoking

Continue smoking while on theophylline

68
Q

Theophylline

+

What drug classes (4)

causes:

HypOkalaemia

As major SE

A

Loop diuretics

Thiazides diuretics

Corticosteroids

Beta2 agonist

69
Q

Theophylline

+

?

Increased risk of seizures

A

Ciprofloxacin

70
Q

Main Tx acute asthma

A

Short acting bronchodilators

&

Oral Corticosteroids

71
Q

Tx

acute asthma (ALTERNATIVE)

A

Short-acting beta-agonists (SABAs)
Salbutamol/terbutaline

Salbutamol by nebuliser (better drug delivery to the lungs 🫁 (O2 driven as BA have a SE atrial hypoxia)

If symptoms persist after 12-30 mints

999

A short course of oral corticosteroids given as a single dose OM

72
Q

Beta 2 agonist

SE

A

Atrial hypoxia

73
Q

Acute Asthma

12 year old on oral corticosteroids

Max days?

And for adults?

A

Up to max 3 days

Adults? Atleast 5 days 40-50mg OM

74
Q

Prednisolone for acute asthma

When is gradual withdrawal required?

A

Can be stopped abruptly

Gradual withdrawal only required if used oral corticosteroids arte taken for more than 3 weeks

75
Q

After acute attack

A

Asthma meds have to be reviewed

bnf 2021 (20 decks)

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