Asthma guidance & drugs Flashcards
How should patients used DPI inhalers?
Need to breathe in fast and strong to create enough turbulence to lift the particles
Why should Beclometasone CFC-free MDIs (QVAR and CLENIL) have their brand endorsed on prescriptions?
What is the combination inhaler also effected by this?
Because they are not interchangeable:
QVAR has extra fine particles that can reach the lungs faster and quicker therefore its more potent (QVAR is 2 x as potent as Clenil)
FOSTAIR also effected- beclometasone and formeterol - its the same as QVAR- has extra fine particles so more potent
Which beta blockers would we be most worried about in asthmatic patients? (5)
Non-cardioselective beta blockers, as these may be more likely to constrict airways:
Propranolol Sotolol Labetolol Carvedilol Timolol
The cardioselective ones (atenolol, bisoprolol) are less of a worry
How should a spacer be cleaned?
Wash it in mild detergent and allow to air dry, wipe mouthpiece free of detergent
Do this once a month (more frequently will effect the electrostatic charge)
How often should a spacer be replaced?
Every 6-12 months
When would nebuliser adrenaline or budesonide be needed?
Child with severe croup
Not severe: oral beclometasone or prednisolone usually used
When should nebulisers be considered in long term management of COPD or asthma?
Remains breathless after two weeks of correctly using optimal therapy
What proportion of nebulised drug will reach lungs?
10-30%
Diluent usually used in nebulisers: NaCl 0.9%
What ages are spacers recommended in children?
Up till the age of 5 for bronchodilators (saba, labas)
Ages 5-15 for ICS
What is the standard length of treatment with steroids for an asthma attack?
Does this differ in children?
Prednisolone oral for 5 days in adult
Prednisolone oral for 3 days in child
IF NBM- IV hydrocortisone every 6 hours until conversion to oral
Can usually abruptly stop the steroid unless the patient has been on oral corticosteroids previously (step 5) for over three weeks
What degree of asthma attack should we consider the use of high flow oxygen?
If it’s severe
We use SABA (e.g. Salbutamol) nebs plus high flow oxygen
Only Saba nebs needed if moderate
If oxygen, SABA and prednisolone are not sufficient for an asthma attack what can be considered?
Ipratropium bromide
IV aminophylline
Magnesium sulphate
If an attack is LIFE-THREATENING: immediately give ipratropium (don’t wait to see if response is poor as with severe asthma attacks)
Which patients are most likely to benefit from an aminophylline infusion in an asthma attack?
Those that have been taking theophylline oral
What is step 1 of the Asthma guidelines
When should a patient be moved on to step 2?
SABA PRN
SABAs used: salbutamol or Terbutaline
Move up if needed more than TWICE a week or woken up once per week
What is step 2 of the asthma guidelines ?
SABA PRN + standard dose of ICS
Recommended starting dose for adults:
400mcg beclometasone daily
Do not go over 800 mcg daily
Max of 2 drugs permitted at step 2
What is step 3 of the asthma guidelines? (Hint: 3 different steps involved)
1) Firstly add in a LABA (salmeterol, formoterol) to the ICS + PRN SABA
2) After addition of LABA can increase ICS dose to 800mcg daily (NB: this is not max dose, just upper end of standard dose range)
If above not worked:
3) stop LABA if no benefit, continue if some benefit
IF LABA STOPPED Consider adding:
Leukotriene receptor agonist (montelukast)
Theophylline MR
Oral MR beta agonists (e.g. Salbutamol tablets/ solution) do not use this in under 12 years
Max of 3 different drugs permitted at this stage
Step 4 of the asthma treatment guidelines? (4 drugs)
The patient will already be on:
SABA PRN + regular standard dose ICS
LABA
1) increase ICS to a over standard dose = regular high dose ICS
Add in a 6 week trial of one or more of:
Leukotriene receptor antagonist (montelukast)
MR theophylline
Oral MR oral beta agonist
Patient on at least 4 drugs at step 4
Step 5 of the asthma treatment guidelines? What 5 different drugs will the patient be on?
Add in regular corticosteroid tablets (prednisolone) refer to a respiratory specialist
Patient will be on: PRN SABA Regular high dose ICS LABA One or more of the leukotriene antagonists, theophylline MR, MR oral beta agonist Regular prednisolone
Stepping down: How often should asthma treatment be reviewed?
Every 3 months
Consider reducing by up to 50% every 3 months
What age of child do the asthma guidelines become different?
Age 5
Child under 5: asthma guidelines step 1?
SABA PRN
Consider moving to step 2 if child needs SABA more than twice per week, is woken at night once a week or had an exacerbation in last 2 years (same as adult guidance)
