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A - BNF CHAPTER 3 - RESP > Airways disease, obstructive > Flashcards

Airways disease, obstructive Flashcards

1
Q

Lifestyle changes include:

A

weight loss, stopping smoking and breathing exercise programmes (as an adjuvant to drug treatment) to improve quality of life + reduce symptoms.

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2
Q

NICE guidance >17 years:

A

SABA (salbutamol or terbutaline) as intermittent reliever therapy
- Refer if using >1 SABA inhaler in 1 month

1) Low dose ICS if patient using SABA >3x weekly, symptomatic >3x weekly, night take awakeness due to asthma
2) LTRA + low dose ICS. Review in 4-8 weeks
3) LABA + low dose ICS, remove LTRA if necessary
4) Consider above as MART regimen
5) Moderate dose ICS
6) High dose ICS or LAMA/theophylline

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3
Q

BTS/SIGN guidance >12 years:

A

SABA as required unless using MART

1) Low Dose ICS
2) Add LABA to low dose ICS (fixed or MART)
3) Increase ICS to medium dose, consider addign LTRA, if no response to LABA stop LABA and consider ICS alone
4) Refer to specialist

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4
Q

Management of Chronic asthma (Adults and children over 5 years)

A

1st Line: Inhaled short-acting beta2 agonist (e.g. Salbutamol) used as required.

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5
Q

When to move from step 1 treatment to step 2

A

If patient presents with any one of the following: using inhaled beta2 agonist 3 times a week or more, being symptomatic 3 times a week or more, waking at night due to asthma at least once a week or had an asthma attack in the last 2 years  MOVE TO STEP 2

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6
Q

Management of Chronic asthma (Adults and children over 5 years) - step 2

A

ADD a Low dose ICS (e.g. Beclometasone, Budesonide, Fluticasone, Mometasone).

  • Fluticasone and Mometasone provide equal clinical activity to Beclometasone and Budesonide at HALF the dosage
  • ICS should be taken initially TWICE daily, however the same TOTAL dose can be taken ONCE daily if good control is established.
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7
Q

In children, administration of high doses of ICS may be associated with

A

growth failure, reduced bone mineral density and adrenal suppression.

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8
Q

Management of Chronic asthma (Adults and children over 5 years) - step 3

A

ADD a Long-acting beta2 agonist (LABA) such as formoterol or salmeterol to be used in conjunction with the ICS.

  • If the patient is gaining some benefit from addition of LABA but control is inadequate, then continue LABA and dose of ICS to medium dose.
  • If there is no response to the LABA, discontinue and dose of ICS.
  • If control is still INADEQUATE, start a trial of either a leukotriene receptor antagonist (e.g. Montelukast),
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9
Q

Management of Chronic asthma (Adults and children over 5 years) - step 4

A

modified-release Theophylline, or modified-release oral beta2 agonist. Leukotriene receptor antagonists are the preferred option in children.
- Before proceeding to Step 5, refer patients with inadequately controlled asthma to specialist care

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10
Q

• STEP 5:

A

ADD a regular oral corticosteroid (Prednisolone as a single daily dose) at lowest dose to provide adequate control
- Continue high dose ICS

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11
Q

Management of Asthma in Pregnancy and Breastfeeding

A
  • When good control of asthma is achieved, it has no important effects on pregnancy, labour or on the fetus.
  • Drugs for asthma should preferably be administered by inhalation to minimise exposure to the fetus.
  • All drugs can be taken as normal during pregnancy, however there is limited information on the use of leukotriene receptor antagonists, but they can be taken if the benefit outweighs the risk.
  • Drugs for asthma including corticosteroid tablets can be used in line with the manufacturer’s recommendation in breast feeding.
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12
Q

Exercise-induced asthma

A

If exercise is a specific problem in patients already taking ICS who are otherwise well controlled consider adding either a Leukotriene receptor antagonist, LABA, an oral beta2 agonist, sodium cromoglicate/nedocromil sodium or Theophylline.

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13
Q

drug of choice before exercise

A

 An inhaled short-acting beta2 agonist used immediately

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14
Q

Moderate-acute asthma

A
  • Increasing symptoms
  • Peak flow >50-75% of best/predicted
  • No features of Severe-acute asthma
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15
Q

Severe-acute asthma (any one of the following)

A
  • Peak flow 33-50% of best/predicted
  • Respiratory rate >25 breaths/min
  • Heart rate >110 beats/min
  • Inability to complete sentences in one breath
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16
Q

Life-threatening acute asthma (any one of the following)

A

• Peak flow <33% of best/predicted
- Exhaustion
• Partial arterial pressure of oxygen (PaO2) <8kPa
• Altered conscious level
- Cyanosis
• Arterial oxygen saturation (SpO2) <92% - Hypotension
• Normal PaCO2 (4.6-6kPa)
- Silent chest
- Arrythmia

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17
Q

Near-fatal acute asthma

A

• Raised PaCO2 requiring mechanical ventilation with raised inflation pressures or both

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18
Q

• First-line treatment for acute asthma

A

a high-dose inhaled short-acting beta2 agonist (Salbutamol) given as soon as possible.

  • If the patient is non-life threatening a pMDI with a spacer is preferred.
  • If the patient is life-threatening a beta2 agonist administered by an oxygen-driven nebuliser is recommended.
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19
Q

• Supplementary oxygen

A

• Supplementary oxygen should be given to all hypoxemic patients with acute-severe asthma to maintain SpO2 levels between 94 - 98%.

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20
Q

• If the response to the initial dose of short-acting beta2 agonist is POOR, consider

A

continuous nebulisation with a nebuliser.

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21
Q

In all cases of acute asthma, patients should be prescribed

A

an adequate dose of oral prednisolone ONCE daily for 5 days (3 days in children) or until recovery.
- Take PO as single dose in morning to reduce disturbance to circadian cortisol secretion

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22
Q

If patient cannot take PO prednisolone, consider

A

parenteral hydrocortisone or IM methylprednisolone

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23
Q

acute-severe or life-threatening asthma or those with a poor initial response to beta2 agonist.

A

• Nebulised Ipratropium bromide may be combined with a nebulised beta2 agonist in patients with acute-severe or life-threatening asthma or those with a poor initial response to beta2 agonist.
- The combination provides greater BRONCHODILATION.

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24
Q

may also be used (senior medical staff).

A

• Magnesium sulfate (bronchodilator) + Aminophylline

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25
Q

Bronchodilators examples

A

SABA: Salbutamol, Terbutaline.

LABA: Formoterol, Salmeterol, Indacaterol, Olodaterol, Vilanterol

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26
Q

Short-acting beta2 agonists

A
  • Inhalation of a selective SABA (Salbutamol) can rapidly treat mild-moderate symptoms of asthma.
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27
Q

Long-acting beta2 agonists

A
  • LABA’s have a role in the long-term management of asthma + can be useful in nocturnal asthma.
    Salmeterol should not be used for an asthma attack due to its slower onset of action. Formoterol is licensed for short-term symptom relief and for the prevention of exercise-induced bronchospasm.
  • Combination inhalers that contain a LABA + Corticosteroid (e.g. Fostair) reduce the flexibility to adjust dose of each component.
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28
Q

Oral beta2 agonists

A
  • Oral preparations are useful for patients who cannot manage the inhaled route.
    But inhaled beta2 agonists are more effective and the have fewer side effects.
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29
Q

Parenteral beta2 agonists

A
  • Salbutamol/ Terbutaline can be given I.V. for severe/life-threatening acute asthma, but regular use is not recommended as evidence of benefit is uncertain and withdrawal of treatment may be difficult
30
Q

Children SABA

A
  • Selective beta2 agonists are useful in children under 18 months and are most effective by the inhaled route.
31
Q

Antimuscarinic bronchodilators examples

A

Ipatropium, Aclidinium, Glycopyrronium, Tiotropium, Umeclidinium

32
Q

Antimuscarinic bronchodilators - action

A

 The maximal effect of Ipratropium bromide occurs 30-60 minutes after use, the duration of action is 3-6 hours and bronchodilation can be maintained with treatment 3x daily. It is a SAMA.

33
Q

Antimuscarinic bronchodilators - Side effects

A

 Dry mouth is the most common side effect and Glaucoma may also occur if given by nebuliser.

34
Q

Antimuscarinic bronchodilators - Tiotropium

A

 Tiotropium (via Respimat device) is licensed as an adjunct to ICS + LABA for maintenance treatment of asthma patients who have suffered 1 or more exacerbations in the last year. It is a LAMA and s.e. is dry mouth. Anoro Ellipta can cause hypokalaemia.

35
Q

Xanthines examples

A

Theophylline, Aminophylline

36
Q

Xanthines

A
  • M.R. Theophylline should be prescribed by brand (Slo-Phyllin) as should Aminophylline.
  • It is a bronchodilator used in asthma and COPD. If given with small doses of beta2 agonists there may be an increased risk of side effects e.g. hypokalaemia.
37
Q

Plasma concentration of theophylline/ aminophylline may decrease with

A

smoking, alcohol and drugs which induce metabolism (phenobarbital and phenytoin)

38
Q

Plasma concentration of theophylline/ aminophylline may increase in

A

HF, hepatic impairment, elderly, viral infections and drugs which inhibit metabolism (CCBs, ciprofloxacin and erythromycin.

39
Q

Theophylline is metabolised

A

• in the liver.

40
Q

Aminophylline is

A

• a stable mixture or combination of theophylline and ethylenediamine; the ethylenediamine confers greater solubility in water.

41
Q

Overdose: (Theophylline, Aminophylline)

A

• They cause vomiting (which may be severe and intractable), agitation, restlessness, dilated pupils, sinus tachycardia, and hyperglycaemia. More serious effects are haematemesis, convulsions, and supraventricular and ventricular arrhythmias. Severe hypokalaemia may develop rapidly.

42
Q

Allergy to ethylenediamine can cause

A

urticaria, erythema, and exfoliative dermatitis.

43
Q

Theophylline during pregnancy

A

• Neonatal irritability and apnoea have been reported. Theophylline can be taken as normal during pregnancy

44
Q

hepatic impairment (Theophylline, Aminophylline)

A

• Consider dose reduction in hepatic impairment

45
Q

• Phyllocontin Continus Forte tablets are for

A

smokers/other patients where theophylline half-life is shorter.

46
Q

Inhaled Corticosteroids

A
  • ICS must be used regularly for maximum benefit; the full effect is seen after 3-7 days.
  • Beclomethasone for inhalation should be prescribed by BRAND, inhalers are not interchangeable
47
Q

ICS Side effects and risk (MHRA)

A
  • Risk of oral candidiasis can be reduced by using a spacer and rinsing the mouth with water.
  • Side effects: Altered taste, voice alteration, headache
  • Risk of Paradoxical bronchospasm means breathing can get worse, resulting in discontinuation of ICS and alternative therapy. Mild bronchospasm may be prevented by inhalation of a short- acting beta2 agonist beforehand (or by transfer from an aerosol inhalation to a dry powder inhalation).
  • MHRA: Rare risk of central serious chorioretinopathy – report blurred vision or any othervisual disturbances
48
Q

LRTA

A
  • The leukotriene receptor antagonist montelukast below blocks the effects of cysteinyl leukotrienes in the airways
  • Prescribers should be alert to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, or peripheral neuropathy.
49
Q

Mast cell stabilisers (Sodium Cromoglicate, Nedocromil Sodium)

A
  • If paradoxical bronchospasm occurs, a fast-acting inhaled bronchodilator such as salbutamol or terbutaline should be used to control symptoms; treatment with nedocromil or sodium cromoglicate should be discontinued.
  • Sodium cromoglicate and nedocromil sodium may also have a role in allergic conjunctivitis; sodium cromoglicate is used also in allergic rhinitis and allergy-related diarrhoea.
50
Q

Salbutamol

- side effects, risks

A
  • Salbutamol causes bronchodilation and lasts for around 3 to 5 hours.
  • Patients on salbutamol are at risk of developing hypokalaemia when given with theophylline or prednisolone. Monitor plasma potassium.
  • Side-effects include fine tremor, nervous tension, headache, cramps and palpitations
51
Q

COPD:

A

Bronchitis: inflammation of the bronchiole tubes in the lung. Following exposure to an irritant (cigarette smoke, air pollution, occupational dust), there is excessive mucous production causing a productive cough. This mucous production also causes an obstruction in the bronchioles making it difficult to breathe out.
- As a result, the FVC and FEV1 are both decreased.

-Emphysema: the alveoli (air spaces) become enlarged.

52
Q

major risk factor for both Bronchitis and Emphysema

A

smoking

53
Q

COPD management

A

Step 1 - SABA (salbutamol) or SAMA (ipratropium)

Step 2:
- FEV1 >50%: LABA (Salmeterol or LAMA)

  • FEV1 <50%: LABA plus ICS or LAMA

Step 3
- LAMA + LABA + ICS

54
Q

Continued COPD management

A
  • If symptoms persist or if the patient is unable to use an inhaler, oral modified-release Theophylline or Aminophylline may be used.
  • A mucolytic drug (Carbocisteine) can be used for a patient with a chronic productive cough. It reduces mucous production + viscosity. Discontinue after 4 weeks if NO IMPROVEMENT.
  • Oxygen therapy (long term) for more than 15 hours reduces mortality. It is given when the partial pressure of oxygen is <7.3kPa. it increases the partial pressure to >8kPa.
  • During an exacerbation, bronchodilator therapy can be given via nebuliser + oxygen given. If the response to nebulised bronchodilators is poor, we can give I.V. Aminophylline.
  • If breathlessness interferes with daily activities give Prednisolone for 7-14 days.
55
Q

BTS/SIGN guidance in paediatrics:

A

Use SABA as required

1) Very low paed. dose ICS (eg. clenil 50) or LTRA if <5y
2) ADD on preventer: >5y add LABA, <5 add LTRA
3) Increase dose of ICS to low dose (Clenil 100), >5y add LTRA or LABA, if no response to LABA, stop LABA
4) Refer to specialist

56
Q

Examples of ICS

A
  • beclometasone (clenil, QVAR)
  • budesonide (pulmicort)
  • ciclesonide OD dosing (alvesco)
  • fluticasone (flixotide)
  • mometasone (asmanex)
57
Q

Examples of LTRA

A

montelukast

58
Q

Examples of LABA

A

salmeterol (long onset + long action), fomoterol (short onset + long action)

59
Q

Important safety information on Beclomethasone

A
  • Branded inhalers (QVAR and Clenil Modulite) are not interchangeable and should be prescribed by brand name. QVAR has extra fine particles, it is more potent than traditional beclomethasone inhalers and is TWICE as potent as Clenil Modulite.
  • When switching a patient with well-controlled asthma from another corticosteroid inhaler… initially 100mcg of QVAR should be prescribed for 200-250mcg of beclomethasone/budesonide.
  • When switching a patient with poor-controlled asthma from another corticosteroid inhaler…initially 100mcg of QVAR should be prescribed for 100mcg of beclomethasone/budesonide.
  • Unlicensed use: Easyhaler not for <18 years, Clenil Modulite 200/250 & Qvar not for < 12 years.
60
Q

Leukotriene receptor antagonists

A
  • Churg-Strauss syndrome occurs very rarely with LTRA. In many cases, the reaction occurs following reduction or withdrawal of oral corticosteroid therapy. Prescribers should be alert for development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications or peripheral neuropathy.
61
Q

stepping down asthma treatment

A

Once patient stable consider dose reductions after 3months, reduce dose by 25%-50% every 3 months

62
Q

Selective B2 Agonists - side effects

A
  • Hand tremor, tachycardia, hyperglycaemia
  • Hypokalemia: potentiated with concomitant corticosteroids, other B2 agonists and theophylline and hypoxia in sever asthma –> monitor serum potassium
  • Serious CVD effects: prolonged QT interval, arrhythmia’s, tachycardia, arterial hypoxia causing MI and hypotension. Take caution in hyperthyroidism
63
Q

ICS side effects

A

Hoarse voice, sore throat, oral candiasis
- paradoxical bronshospasm: stop and give alternative. if its mild bronchospasm use SABA beforehand or transfer from pMDI to DPI

64
Q

LTRA side effects

A

Churg strauss syndrome: occurs on wtihdrawal or reduces of PO corticosteroid. Stay alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications and peripheral neuropathy

65
Q

Theophylline

A
  • Narrow therapeutic drug: 10-20mg/L. Sample 4-6h after dose
  • SIgns of toxicity: FAST AND SICK:
  • Vomiting and GI effects initially
  • Tachycardia, CNS stimulation (restlessness, agitation, dilated pupils)
  • Arrhythmia’s, convulsions and hypokalaemia
66
Q

Theophylline interactions:

A
  • Increased risk of hypokalaemia = loop/thiazide diuretics, corticosteroids, B2 agonists
  • Increased risk of convulsions = ciprofloxacin
  • Increased plasma conc. and risk of toxicity = verapamil/ CCB, cimetidine, phenytoin, fluconazole, macrolide
  • Reduced plasma conc. is sub-therapeutic = St johns wort, rifampicin
67
Q

Medical emergency: acute asthma

A
  • 2 to 10 puffs every 10-20mins or PRN or
  • Salbutamol/terbutalien nebuliser every 20-30 mins or PRN
  • If symptoms persist after 15-30 mins call 999
  • Repeat above and add nebulised ipratropium bromide

PLUS in all cases of acute asthma:
Prednisolone tabs or IV HC
- Child <12: upto 3 days
- Adults: Atleast 5 days

68
Q

Sever COPD with hypoxaemia

A
  • Oxygen therapy
  • 15h a day or more prolongs survival
  • 88-92% O2 Sat. (risk of hypercapnic respiratory failure)
  • Must carry )2 alert card and use a 24% or 28% venturi mask if history of hypercapnic respiratory failure
69
Q

SAMA

A
  • Ipratroprium
70
Q

LAMA

A
  • Aclidinium
  • Glycopyronnium
  • Umeclidinium
  • Tiotropium
71
Q

Inhaled antimuscarinics cautions

A
  • Prostatic hyperplasia
  • Risk of angle-closure glaucoma. Acute angle-clsure glaucoma reported with nebulised ipratropium especially when given with salbutamol. Protect eyes
72
Q

Inhaled antimuscarinics side effects

A
  • dry mouth
  • paradoxical bronchospasm (unexpected constriction of smooth muscle walls of the bronchi that occurs in the setting of an expected bronchodilatory response)

A - BNF CHAPTER 3 - RESP (7 decks)

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