BNF Chapter 3: The Respiratory System Flashcards
What is acute asthma?
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 and FEV1.
What is the first-line treatment for acute asthma?
A short-acting beta2 agonist (SABA), such as salbutamol, given as soon as possible.
What should all patients with acute asthma be prescribed?
Prednisolone
What is chronic asthma?
A chronic inflammatory condition of the airways, associated with airway hyperresponsiveness and variable airflow obstruction.
Most frequent symptoms are cough, wheeze, chest tightness and breathlessness.
What is complete asthma control defined as?
No daytime symptoms, no night-time awakening due to asthma, not asthma attacks, no need for rescue medication, no limits on activity including exercise, normal lung function and minimal side-effects from treatment.
Management of Chronic Asthma in Adults
Intermittent reliever therapy
-Start an inhaled short-acting beta2 agonist (salbutamol or terbutaline) to be used prn. For adults with normal lung function and infrequent wheeze, consider treatment with SABA alone.
Regular preventer (maintenance) therapy
-Low dose ICS started as maintenance therapy for patients with one or more following features: using reliever therapy 3x weekly or more, symptomatic 3x weekly or more, waking at night due to asthma symptoms at least once a week.
-ICS should be taken BD- dose adjusted over time to lowest effective dose
-ICS include beclometasone, budesonide, ciclesonide, fluticasone and mometasone.
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What criteria should be met for an adult with chronic asthma to be prescribed a low dose ICS, alongside their regular intermittent reliever therapy?
If the patient meets one of the following: using their preventer/maintenance therapy 3x week or more, waking at night due to asthma symptoms weekly or symptomatic three times a week or more.
Initial Add-On Therapy
-If asthma uncontrolled on low dose ICS as maintenance therapy, try a leukotriene receptor antagonist (LTRA)- montelukast is first-line.
-Review treatment response in 4-8 weeks
-Can also try a long-acting beta2 agonist (LABA) such as salmeterol or formoterol as initial add-on therapy to low dose ICS if asthma is uncontrolled after trying a LTRA. Can either continue LTRA too or stop.
Can be given as a fixed-dose ICS and LABA regimen, but can swap to a MART regimen (Maintenance and Reliever therapy) if ineffective- combination of ICS and a fast-acting LABA such as formoterol.
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Chronic Asthma in Children
-Start on a short-acting beta2 agonist (salbutamol or terbutaline)
-Regular preventer (maintenance) therapy can be ICS at a low dose.
-Montelukast can be initial add-on therapy if asthma is uncontrolled.
In children under 5:
-Start SABA
-SABA + 8 week trial of paediatric moderate-dose ICS
What is COPD?
A common, largely preventable and treatable disease, characterised by persistent repiratory symptoms and airflow limitation that is usually progressive and not fully reversible.
What is the main risk factor for developing COPD?
Tobacco smoking
Non-Drug Treatment for COPD
-Stop smoking
-Breathing techniques, and how to use positive expiratory pressure devices if excessive sputum production.
-BMI and weight support if needed
-Offer pneumococcal vaccine and annual influenza
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Drug Management of COPD
-Short-acting bronchodilator (SABA or SAMA)- relieve breathlessness and exercise limitation
-Offer LABA + LAMA if still having breathlessness and problems, and DO NOT have asthmatic features/features suggesting steroid responsiveness; if a LAMA is given then the SAMA must be discontinued.
-If a pt has symptoms suggesting steroid responsiveness/asthmatic symptoms, then can try LABA + ICS instead.
Triple therapy: LABA + ICS + LAMA
-If pt is on LABA+ICS, consider this if their symptoms are still impacting their life, or if they have had a severe exacerbation requiring hospital or two moderate exacerbations in a year.
-If pt is on LAMA+LABA, consider if they have had a severe exacerbation requiring hospitalisation or have had two moderate exacerbations in a year.
Consider a 3 month trial if pt is on LAMA+LABA- if improvement in symptoms, continue. If no improvement, stop triple therapy and return to just LAMA+LABA.
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When should azithromycin be considered as prophylaxis in patients with COPD, to reduce the risk of exacerbations?
If the patient is a non-smoker, had all treatments optimised and they continue to have prolonged or frequent (4 or more a year) exacerbations with sputum production, or hospitalisations.
What are the common symptoms of COVID-19?
Fever
A new continuous cough
Loss or change in sense of smell or taste
Loss of eppetite
Nausea and vomiting
Diarrhoea
SOB
Fatigue
Muscle aches
Headache
Sore throat
Nasal congestion
What are some potential life threatening complications of COVID-19?
Thromboembolic events
Cardiac disease
Acute kidney injury
Sepsis
Septic shock
Multi-organ failure
Drug Treatment for COVID-19
-Offer Dexamethasone if the patient needs supplemental oxygen- hydrocortisone or prednisolone are suitable alternatives if dexamethasone is CI.
-Tocilizumab should be offered to patients in hospital with COVID-19 if they meet the criteria.
What is Cystic Fibrosis?
A genetic disorder affecting the lungs, pancreas, liver, intestine and reproductive organs.
What are the aims of cystic fibrosis treatment?
-Preventing and managing lung infections- WANT TO OPTIMISE LUNG FUNCTION
-Loosening and removing thick mucus from the lungs
-Preventing or treatment intestinal obstruction
-Supplementing nutrition and hydration
Mucolytics in Cystic Fibrosis
-Dornase alfa is first-choice; if inadequate response, then hypertonic sodium chloride can be added.
Pulmonary infection:
-Long-term antibacterial should be considered to suppress chronic Staph.aureus infections
What are the three types of influenza?
Influenza A: more virulent and occurs more frequently
Influenza B: a milder disease but can still cause outbreaks
Influenza C: mild or asymptomatic, similar to a cold
Influenza is either complicated or uncomplicated. In which patient groups is complicated infection more likely? (Hopsitalisation, lower respiratory tract infection, CNS involvement)
Children under 6 months
Pregnant women
Over 65s
Patients with respiratory, renal, hepatic, neurological or cardiac disease
Diabetes
Morbid obesity
Severe immunosuppression
Which two antivirals can be used to treat influenza?
Oseltamivir
Zanamivir
