BNF - Chapter 3 - Respiratory System Flashcards
Where does inhalation deliver drugs to?
Directly to the airways;
Is the dose required via inhalation route more or less than when given by mouth?
the dose required is smaller than when given by mouth and side-effects are reduced.
What are the three types of of inhaler devices?
- Pressurised metered-dose inhalers
- Breath-actuated inhalers
- Dry powder inhalers
Why are spacer devices useful, what do they remove the need of?
Spacer devices remove the need to co-ordinate actuation with inhalation
Are dry powder inhalers suitable for those under 5?
No
Who are dry powder inhalers suitable or may be used for?
Maybe useful for adults and children over 5 years who are unwilling or unable to use a pressurised metered-dose inhaler
Is there evidence to suggest an order in which the types of inhaler devices should be tested?
No
When should a spacer be always used?
When the patient is on a high dose of inhaled corticosteroids
With adults with mild or moderate acute asthma attacks, what is at least as effective as nebulisation?
- a pressurised metered-dose inhaler with a spacer
When changing from a pressurised metered-dose inhaler to a dry powder inhaler, what may patients notice?
- A lack of sensation in the mouth and throat previously associated with each actuation.
- Coughing may also occur
What does a spacer device do?
- removes the need for co-ordination between actuation of a pressurised metered-dose inhaler and inhalation.
- The spacer device reduces the velocity of the aerosol and subsequent impaction on the oropharynx and allows more time for evaporation of the propellant so that a larger proportion of the particles can be inhaled and deposited in the lungs.
Who are spacer devices particularly useful for?
- Patients with poor inhalation technique
- For children
- For patients requiring high doses of inhaled corticosteroids
- for nocturnal asthma
- patients prone to candidiasis with inhaled corticosteroids
Are spacer devices regarded as being interchangable?
No, patients should be advised not to witch between spacer devices
How often and how should the spacer device be washed?
- Should be cleaned once a month
- by washing in mild detergent before use
- Some manufacturers recommend more frequent cleaning, but this should be avoided since any electrostatic charge may affect drug delivery
How often should spacer devices be replaced?
- every 6-12 months
When are solutions for nebulisation used?
- in severe or life-threatening asthma attacks
Over how many minutes are solutions for nebulisation administered from a nebuliser?
Over 5 - 10 minutes and are usually driven by oxygen
What can beta-2 agonists increase the risk of?
- arterial hypoxaemia
Why should patients with a severe attack of asthma preferably have oxygen during nebulisation?
- Since beta2 agonists can increase arterial hypoxia.
- However, the absence of supplementary oxygen should not delay treatment
What does a nebuliser do in terms of particle?
A nebuliser converts a solution of a drug into an aerosol for inhalation.
Are higher doses of drug given via inhaler or nebuliser?
A nebuliser
- it is used to deliver higher doses of drug to the airways than is usual with standard inhalers.
What are the main indications for the use of a nebuliser?
- a beta2 agonist or ipratropium bromide to a patient with an acute exacerbation of asthma or of COPD
- a beta2 agonist, corticosteroid, or ipratropium bromide on a regular basis to a patient with severe asthma or reversible airways obstruction when the patient is unable to use other inhalation devices;
- an antibiotic (such as colistimethate sodium) or mucolytic to a patient with cystic fibrosis
- budesonide or adrenaline/epinephrine to a child with severe croup
- petamidine isetionate for the prophylaxis and treatment of pneuocystis pneumonia
Before prescribing a nebuliser, what should be trialed?
- a home trial should be undertaken to monitor response for up to 2 weeks on standard treatment and up to 2 weeks on nebulised treatment
What proportion (percentage) of a nebuliser solution reaches the lungs?
- depends on the type of nebuliser and although it can be as high as 30%, it is more frequently close to 10% and sometimes below 10%.
If 30% of nebuliser solution or more commonly 10% of it reaches the lungs then what happens to the rest of the nebuliser solution?
- The remaining solution is left in the nebuliser as residual volume or is deposited in the mouthpiece and tubing.
The extent to which nebulised solution is deposited in the airways or alveoli is dependent on what?
- droplet size, pattern of breath inhalation, and condition of the lung.
Where are droplets with a mass median diameter of 1-5 microns depositied?
Deposited in the airways and are therefore appropriate for asthma
Where are particles sized 1-2 microns depostied?
- alveolar deposition
- good for pentamidine isetionate to combat pneumocystis infection.
Are jet nebulisers used more widely than ultrasonic nebulisers?
Yes
What do most jet nebulisers require an optimum gas flow rate level of?
Flow rate of 6-8 litres/minute and in hospital can be driven by piped air or oxygen
In acute asthma what should the jet nebuliser be driven by?
by oxygen
Domicilliary oxygen cylinders do not provide an adequate flow rate therefore what should be used?
An electrical compressor is required for domicilliary use
What is hypercapnia?
It is a build up of carbon dioxide in the blood stream.
it affects people who have COPD.
For patients at risk of hypercapnia such as those with COPD, what should the nebuliser be driven by and why?
oxygen can be dangerous and the nebuliser should be driven by air.
If oxygen is required, it should be given simultaneously by nasal cannula.
How do ultrasonic nebulisers work?
- Ultrasonic nebulisers produce an aerosol by ultrasonic vibration of the drug solution and therefor do not require a gas flow
- They are not suitable for the nebulisation of some drugs, such as dornase alfa and nebulised suspensions.
What is the usual nebuliser diluent?
Nebulisation may be carried out using an undiluted nebuliser solution or it may require dilution beforehand.
The usual diluent is sterile sodium chloride 0.9% (physiological saline).
In England and Wales are nebulisers and compressors available on the NHS?
nebulisers and compressors are not available on the NHS (but they are free of VAT);
what is the disadvantage of giving drugs orally than by inhalation?
More systemic side effects
Which drugs can be given by mouth for the treatment of asthma?
- Corticosteroids
- Theophylline
- Leukotriene receptor antagonists (e.g. Montelukast)
Which drugs can be given parenterally for asthma?
- beta 2 agonists
- Corticosteroids
- Aminophylline (can be given by injection in severe acute and life-threatening asthma when administration by nebulisation is inadequate or inappropriate).
Who may peak flow meters benefit?
measurement of peak flow may be of benefit in adult patients who are ‘poor perceivers’ and hence slow to detect deterioration in their asthma, and for those with more severe asthma.
What are the most frequent symptoms of asthma?
- Cough
- Wheeze
- Chest tightness
- Breathlessness
Asthma symptoms vary over time and in intensity and can gradually or suddenly worsen, provoking an acute asthma attack that, if severe, may require hospitalisation.
What is asthma- COPD overlap syndrome characterised by?
- by persistent airflow limitation displaying features of both asthma and COPD
What is complete control of asthma defined as?
- As having no daytime symptoms,
- No night-time awakening due to asthma,
- no asthma attacks
- no need for rescue medication
- no limitations on activity including exercise,
- Normal lung function (in practical terms forced expiratory volume in 1 second (FEV1) and or peak expiratory flow (PEF) >80% predicted or best), and minimal side effects from treatment.
What lifestyle changes can be promoted for chronic asthma?
- Weight loss
- smoking cessation
- breathing exercise programmes (can be offered to adults as an adjuvant to drug treatment to improve quality of life and reduce symptoms).
What should be offered or in place for all patients with asthma (and/ or their family or carers)?
- A self-management programme comprising of a written personalised action plan and education
- and supported with regular review by a healthcare professional
What ages do NICE and BTS/SIGN recommendations on adults refer to?
BTS/SIGN = over 12 years
What should patients be started on for chronic asthma?
Intermittent reliever therapy
- Start an inhaled short acting beta 2 agonist (such as salbutamol or terbutaline) to be used as required in all patients with asthma.
Patients using more than how many short acting beta 2 agonist inhaler device a month should be urgently assessed?
more than 1 device
Patients using more than one short-acting beta2 agonist inhaler device a month should have their asthma urgently assessed and action taken to improve poorly controlled asthma.
What maintenance therapy should be used in control of chronic asthma?
Regular preventer (maintenance) therapy
A low dose of ICS should be started as maintenance therapy in patients who present with any one of the following features:
- using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week.
What frequency of administration is recommended of the reliver (maintenance) therapy?
recommend that inhaled corticosteroids (except ciclesonide) should initially be taken twice daily, however the same total daily dose taken once a day, can be considered in patients with milder disease if good or complete control of asthma is established.
What dose BTS/SIGN recommend in terms of prescribing inhalers?
Prescribing by brands
What is the initial add on therapy if asthma is uncontrolled on a low-dose of ICS as maintenance therapy?
- Add a leukotriene receptor antagonist (LTRA- such as Montelukast) as an addition to ICS, and response to treatment reviewed in 4 to 8 weeks.
What does BTS/SIGN recommend instead for intiial add on therapy if low-dose ICS is not adequate at controlling asthma symptoms?
- Recommend a long-acting beta2 agonsit (LABA - such as salmeterol or formoterol)
- can be given as either a fixed doe ICS and LABA regimen or a MART regimen (maintenance and reliver therapy - a combination of an ICS and a fast acting LABA such as formoterol in a single inhaler (Fostair)
IF asthma is uncontrolled on a low-dose of ICS and LTRA as maintenance therapy, then what should be added?
a LABA in combination with the ICS should be offered with or without continued LTRA treatment, depending on the response achieved from the LTRA
If asthma remains uncontrolled what should be changed/ or added?
If asthma remains uncontrolled, offer to change the ICS and LABA maintenance therapy to a MART regimen, with a low-dose of ICS as maintenance.
What if asthma still remains uncontrolled on MART regimen and low dose ICS?
consider increasing to a moderate-dose of ICS (either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy).
If asthma is still uncontrolled in patients on a moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), with or without a LTRA then what should be considered next steps?
Increasing the ICS dose to a high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist used as reliever therapy), or
A trial of an additional drug, for example, a long-acting muscarinic receptor antagonist (such as tiotropium) or modified-release theophylline, or
Seeking advice from an asthma specialist
Under specialist advice what further add on treatments are available?
Under specialist care, BTS/SIGN (2019) recommend that if asthma control remains inadequate on a medium-dose of ICS, plus a LABA or LTRA, the following interventions can be considered:
Increasing the ICS to a high-dose—with high doses of ICS via a pressurised metered dose inhaler (pMDI) a spacer should be used, or
Adding a LTRA (if not already tried), or modified-release theophylline, or tiotropium.
If a trial of a further add-on treatment is ineffective, stop the drug (or in the case of increased dose of ICS, reduce to the original dose).
Can frequent use of corticosteroids be used under specialist therapies?
Yes - recommend adding a regular oral corticosteroid (prednisolone) at the lowest dose to provide adequate control in patients with very severe asthma uncontrolled on a high-dose ICS, and who have also tried (or are still receiving) a LABA, LTRA, tiotropium, or modified-release theophylline.
Which monoclonal antibodies can be used in controlling severe asthma?
Under specialist initiation, BTS/SIGN (2019) recommend that monoclonal antibodies such as omalizumab (for severe persistent allergic asthma), mepolizumab, benralizumab and reslizumab (in adults for severe eosinophilic asthma), and immunosuppressants such as methotrexate [unlicensed], may be considered in patients with severe asthma to achieve control and reduce the use of oral corticosteroids
Which intermittent reliver therapy is recommended for children 5 years and over (5 - 16 years)?
- start an inhaled short acting beta 2 agonist (such as salbutamol or terbutaline)
What regular preventer (maintenance therapy) is recommended in children?
- A paediatric low dose of ICS should be started as maintenance therapy in children who present with any on e of the following;
using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week.
For children what is the initial add on therapy?
If asthma is uncontrolled on a paediatric low-dose of ICS as maintenance therapy, consider a leukotriene receptor antagonist (LTRA—such as montelukast) in addition to the ICS, and review the response to treatment in 4 to 8 weeks.
For children, like similar to adults what does BTS/SIGN recommend instead as initial add on therapy?
BTS/SIGN (2019) instead recommend a long-acting beta2 agonist (LABA—such as salmeterol or formoterol fumarate) as initial add-on therapy to low-dose ICS if asthma is uncontrolled in children aged over 12 years.
- fixed or MART combination
If asthma is uncontrolled in a child 5-16 years old on a paediatric low-dose of ICS and a LTRA as maintenance therapy, what should be considered
consider discontinuation of the LTRA and initiation of a LABA in combination with the ICS.
If asthma remains uncontrolled on a paediatric low-dose of ICS and a LABA as maintenance therapy, consider changing to a MART regimen (Maintenance And Reliever Therapy—a combination of an ICS and fast-acting LABA such as formoterol in a single inhaler) with a paediatric low-dose of ICS as maintenance.
If asthma remains uncontrolled in a child aged 5-16 on a MART regimen with a paediatric low-dose of ICS as maintenance, what should be considered next?
consider increasing to a paediatric moderate-dose of ICS (either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy).
If asthma is still uncontrolled in a child aged 5-16 on a paediatric moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), what should be considered next?
consider seeking advice from an asthma specialist and the following options:
Increasing the ICS dose to a paediatric high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist as reliever therapy), or
A trial of an additional drug, such as modified-release theophylline.
Under specialist care can an oral corticosteroid be used long term for treatment of asthma in children aged 5-16?
Under specialist care, BTS/SIGN (2019) recommend adding a regular oral corticosteroid (prednisolone) at the lowest dose to provide adequate control in children with very severe asthma uncontrolled on a high-dose ICS, and who have also tried (or are still receiving) a LABA, LTRA, tiotropium (child over 12 years), or modified-release theophylline.
Which children (age) can tiotropium be considered?
Over 12 years
Which monoclonal antibodies can be considered in children?
Under specialist initiation, BTS/SIGN (2019) recommend that monoclonal antibodies such as omalizumab (child over 6 years for severe persistent allergic asthma), and immunosuppressants such as methotrexate [unlicensed] can be considered in children with severe asthma to achieve control and reduce the use of oral corticosteroids.
When treating chronic asthma in children under age of 5, what intermittent reliever therapy is recommended?
- A short acting beta 2 agonist (such as salbutamol) as a reliver therapy.
For children under 5, for asthma what regular preventer (maintenance) therapy is recommended?
Consider an 8-week trial of a paediatric moderate-dose of ICS in children presenting with any of the following features: asthma-related symptoms three times a week or more, experiencing night-time awakening at least once a week, or suspected asthma that is uncontrolled with a short-acting beta2 agonist alone.
After 8 weeks of the trail of moderate ICS what should you do next for the child (under 5 years)?
After 8 weeks, stop ICS treatment and continue to monitor the child’s symptoms:
If symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely;
If symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low-dose as first-line maintenance therapy;
If symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8-week trial of a paediatric moderate-dose of ICS
What is the initial add on therapy for treating asthma for child under 5?
If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS as maintenance therapy, consider a leukotriene receptor antagonist (LTRA—such as montelukast) in addition to the ICS.
If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS and a LTRA as maintenance therapy, stop the LTRA and refer the child to an asthma specialist.
After how many months of current well controlled maintenance therapy should you consider decreasing maintenance therapy?
At least three months
Furthermore, reductions should be considered every three months, decreasing the dose by approximately 25-50% each time.
What is exercise induced asthma a sign of?
- Poorly controlled asthma and regular treatment including ICS should therefore be reviewed.
If exercise is a specific problem in patients already taking an ICS who are otherwise well controlled, what should you consider adding to treatment?
consider adding either a LTRA, a long-acting beta2 agonist, sodium cromoglicate or nedocromil sodium, or theophylline
An inhaled short-acting beta2 agonist used immediately before exercise is the drug of choice.
Women with asthma should be closely monitored during pregnancy, true or false?
TRue
Which drugs can be used as normal to manage asthma in pregnant women?
Short-acting beta2 agonists, LABAs, oral and inhaled corticosteroids, sodium cromoglicate and nedocromil sodium, and oral and intravenous theophylline (with appropriate monitoring) can be used as normal during pregnancy.
Which drug used in asthma treatment should be used with caution or only if needed when treating pregnant women?
here is limited information on use of a LTRA during pregnancy, however, where indicated to achieve adequate control, they should not be withheld.
As summary of the management of Chronic Asthma (adults and children over 5 years) what is the 1st line treatment?
- Inhaled short acting beta 2 agonist (e.g. salbutamol) used as required
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, experiencing night-time symptoms atleast once a week or had an asthma attack in the last 2 years — MOVE TO STEP 2
What is second line?
• ADD a regular inhaled standard-dose corticosteroid (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
In children. administration of high doses of ICS may be associated with what?
- Growth failure
- Reduced bone mineral density
- adrenal suppression
What is third line/ step 3?
• 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 increase dose of ICS to top end of the range.
- If there is no response to the LABA, discontinue and increase dose of ICS.
- If control is still INADEQUATE, start a trial of either a leukotriene receptor antagonist (e.g. Montelukast), 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
Step 3 is up until Leukotriene receptor antagonist and Theophylline.
Step 4 is modified-release oral beta2 agonist.
What is step 5 of chronic asthma management?
- Before proceeding to Step 5, refer patients with inadequately controlled asthma to specialist care
ADD a regular oral corticosteroid (Prednisolone as a single daily dose) at lowest dose to provide adequate control
- Continue high dose ICS
Summarise the treatment steps of chronic asthma in children under 5 years old?
Management of Asthma in Children under 5 years is essentially the same as with adults and children over 5:
Step 1 and 2 are the same.
But at Step 2, if child cannot take ICS, give a Leukotriene-receptor antagonist instead.
At Step 3, add a leukotriene receptor antagonist if it was not added at step 2. But if a leukotriene receptor antagonist was added, reconsider adding an ICS.
Step 4 refer child to respiratory paediatrician.
In pregnant women how are drugs for asthma preferred to be delivered?
Via inhalation to minimise exposure to the fetus
What is the drug of choice for exercise-induced asthma?
- A inhaled short acting beta 2 agonist immediately before exercise
What is acute asthma?
It is the progressive worsening of asthma symptoms, including breathlessness, wheeze, cough, and chest tightness.
An acute exacerbation is marked by a reduction in baseline objective measures of pulmonary function, such as peak expiratory flow rate and FEV1
Do most asthma attacks that require hospitalisation develop quickly or slowly?
Most asthma attacks severe enough to require hospitalisation develop relatively slowly over a period of six hours or more.
In children, what can intermittent wheezing attacks be usually triggered by?
Viral infections and response to asthma medication may be inconsistent
What may be risk factors for recurrent wheeze?
Low birth weight
and/ or prematurity
In order to appropriately treat acute exacerbation of asthma what should be correctly differentiated?
Severity should be categorised from poor asthma control
What is described as moderate acute asthma?
- Increasing symptoms
- Peak flow >50-75% best or predicted
- No features of acute severe asthma
What is described as severe acute asthma?
- Peak flow 33-50% best or predicted
- Respiratory rate > or equal to 25/min
- Heart rate ≥ 110/min
- Inability to complete sentences in one breath
What is described as life-threatening acute asthma?
Any one of the following in a patient with severe asthma:
Peak flow
What is described as near-fatal acute asthma?
Raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures
In children, what is described as moderate acute asthma?
Able to talk in sentences;
Arterial oxygen saturation (SpO2) ≥ 92%;
Peak flow ≥ 50% best or predicted;
Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years;
Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years
In children, what is described as severe acute asthma?
Can’t complete sentences in one breath or too breathless to talk or feed;
SpO2 140/minute in children aged 1–5 years; heart rate > 125/minute in children aged over 5 years;
Respiratory rate > 40/minute in children aged 1–5 years; respiratory rate > 30/minute in children aged over 5 years
In children what is described as life-threatening acute asthma?
Any one of the following in a child with severe asthma:
SpO2
What is the difference in he location/ environment/ setting in which different levels of asthma severity is treated?
Moderate = treated at home or in primary care
Severe or life-threatening = ASAP and be referred to hospital immediately
Who should supplementary oxygen be given to?
To all hypoxaemic patients with severe acute asthma to maintain an SpO2 level between 94-98%.
Do not delay if pulse oximetry is unavailable
What is the first line treatment of acute asthma?
- A high dose short acting beta 2 agonist (such as salbutamol) given as soon as possible.
For patient with mild to moderate acute asthma - how is the beta 2 agonist given?
For patients with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer can be used.
For patients with acute severe or life-threatening symptoms, how is administration of beta 2 agonist given?
Administration via an oxygen-driven nebuliser is recommended, if available.
If the response to an initial dose of nebulised short-acting beta2 agonist is poor, consider continuous nebulisation with an appropriate nebuliser.
Who are intravenous beta 2 agonists reserved for?
For those patients in whom inhaled therapy cannot be used reliably.
In all cases of acute asthma, what must patients be prescribed?
An adequate dose of oral prednisolone.
Should ICS still be continued during oral corticosteroid treatment?
Yes
What are alternatives to patients who are unable to take oral prednisolone?
- Parenteral hydrocortisone
- intramuscular methylprednisolone
To provide greater bronchodilation, in which patients may nebulised ipratropium bromide be combined with a nebulised beta 2 agonist in patients?
in patients with severe or life-threatening acute asthma, or in those with a poor initial response to beta2 agonist
Which compound has should to have some evidence in having bronchodilator effects?
Magnesium sulfate
In which patients may intravenous magnesium sulfate be considered?
A single intravenous dose of magnesium sulfate may be considered in patients with severe acute asthma (peak flow
When is aminophylline considered in the treatment of acute asthma?
In an acute asthma attack, intravenous aminophylline is not likely to produce any additional bronchodilation compared to standard therapy with inhaled bronchodilators and corticosteroids. However, in some patients with near-fatal or life-threatening acute asthma with a poor response to initial therapy, intravenous aminophylline may provide some benefit.
Magnesium sulfate by intravenous infusion or aminophylline should only be used after consultation with who?
After consultation with a senior medical staff.
Moving on to the management of acute asthma in children aged 2 years and over, who is supplementary high flow oxygen given to?
Supplementary high flow oxygen (via a tight-fitting face mask or nasal cannula) should be given to all children with life-threatening acute asthma or SpO2
In children over , what is first line treatment of acute asthma?
an inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible.
When should parents/carers of children with acute asthma at home seek urgent medical attention if initial symptoms are not controlled with up to how many puffs of salbutamol via a spacer?
Up to 10 puffs.
if symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention
Urgent medical attention should be sought id the child’s symptoms return within how many hours?
Within 3 to 4 hours
if symptoms return within this time, a further or larger dose (maximum of 10 puffs of salbutamol via a spacer) should be given whilst awaiting medical attention
In all cases of acute asthma, children should be given an oral dose of what?
Oral prednisolone
How many days treatment of oral prednisolone is sufficient in children for acute asthma?
Treatment for up to 3 days, but the length of the course should be tailored to the number of days necessary to bring about recovery.
Repeat the dose in children who vomit and consider the intravenous route in those who are unable to retain oral medication.
Can ICS be replaced for oral prednisolone while on acute asthma treatment or vice versa?
It is considered good practice that inhaled corticosteroids are continued at their usual maintenance dose whilst receiving additional treatment for the attack, but they should not be used as a replacement for the oral corticosteroid.
Similarly to adult, can nebulised ipratropium bromide be combined with a nebulised beta 2 agonist for children with a poor initial response to beta 2 agonist therapy?
Yes to provide a greater bronchodilation
Is magnesium sulfate use a licenced use in children for acute asthma?
Consider adding magnesium sulfate [unlicensed use] to each nebulised salbutamol and ipratropium bromide in the first hour in children with a short duration of severe acute asthma symptoms presenting with an oxygen saturation less than 92%.
What intravenous options are there for children with acute asthma?
In children who respond poorly to first-line treatments, intravenous magnesium sulfate [unlicensed use] may be considered as first-line intravenous treatment. In a severe asthma attack where the child has not responded to initial inhaled therapy, early addition of a single bolus dose of intravenous salbutamol may be an option.
Continuous intravenous infusion of salbutamol, administered under specialist supervision with continuous ECG and electrolyte monitoring, should be considered in children with unreliable inhalation or severe refractory asthma
Can aminophylline be used as an option in children over 2 years?
Intravenous aminophylline may be considered in children with severe or life-threatening acute asthma unresponsive to maximal doses of bronchodilators and corticosteroids.
Where should children under 2 years be treated for acute asthma?
In hospital setting
What are the treatment options for children under 2 with acute asthma?
For moderate and severe acute asthma attacks, immediate treatment with oxygen via a tight-fitting face mask or nasal prongs should be given to achieve normal SpO2 saturations of 94-98%. Trial an inhaled short-acting beta2 agonist and if response is poor, combine nebulised ipratropium bromide to each nebulised beta2 agonist dose. Consider oral prednisolone daily for up to 3 days, early in the management of severe asthma attacks.
What should be done after every case of acute asthma?
follow up in all cases
Episodes of acute asthma may be a failure of preventative therapy, review is required to prevent further episodes. A careful history should be taken to establish the reason for the asthma attack. Inhaler technique should be checked and regular treatment should be reviewed.
Patients should be given a written asthma action plan aimed at preventing relapse, optimising treatment, and preventing delay in seeking assistance in future attacks.
Within how many days of hospital discharge, following an acute asthma attack should the GP review the patient?
It is essential that the patient’s GP practice is informed within 24 hours of discharge from the emergency department or hospital following an asthma attack, and the patient be reviewed by their GP within 2 working days.
For how long should a respiratory specialist follow up all patients admitted with a severe asthma attack?
For at least one year after the admission
What effect do beta 2 agonists produce?
Bronchodilation
Which is the most and effective SABA for asthma?
Salbutamol
Given an example of a less selective beta 2 agonist?
Ephedrine -
Less selective beta 2 agonist such as ephedrine are less safe for use as bronchodilators than selective drugs, because they are more likely to cause arrhythmias + other side effects
What can inhalation of selective SABA (salbutamol) treat?
Can rapidly treat the mild-moderate symptoms of asthma
What role do LABAs (e.g. Salmeterol/ formoterol) have in the management of asthma?
- Role in long term management
- Also can be useful in nocturnal asthma
Can salmeterol be used be used for an asthma attack?
No due to its slower onset of action
Is Formoterol licensed for short-term symptom relief?
Yes and for the prevention of exercise induced bronchospasm
FA (Fast acting) - LABA
Who are oral preparations of oral beta 2 agonist can useful for?
For patients who cannot manage the inhaled route
are inhaled or oral beta 2 agonists more effective?
Inhaled beta 2 agonists are more effective than oral beta 2 agonists.
Oral beta 2 agonists have more side effects
For which severity of acute asthma can salbutamol/terbutaline be given intravenously?
- 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.
Can selective beta 2 agonists be used in children under 18 months?
YEs and most are effective by the inhaled route.
What type of bronchodilator is ipratropium bromide?
Antimuscarinic bronchodilator
It is a SAMA
Short-acting Muscarinic antagonist
How long after administration does the maximal effect of ipratropium bromide occur?
30-60 minutes after use.
What is the duration of action of ipratropium bromide?
3-6 hours and bronchodilation can be maintained with treatment 3x daily
What is the most common side effect of ipratropium bromide?
- dry mouth is the most common side effect and glaucoma may also occur if given by nebuliser
What is the bronchodilator category for tiotropium (via respimat device)?
LAMA
