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My Pham Notes > Chapter 3: Respiratory system > Flashcards

Chapter 3: Respiratory system Flashcards

1
Q

How should patients used DPI inhalers?

A

Need to breathe in fast and strong to create enough turbulence to lift the particles

these are breath actuated inhalers. Symbicort is an example. You can get a symbicort whistle to test if the patient has the ability to use the inhaler. If they breath in strong enough it will make a noise

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2
Q

Why should Beclometasone CFC-free MDIs (QVAR and CLENIL) have their brand endorsed on prescriptions? What is the combination inhaler also effected by this?

A

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 affected- has extra fine particles (beclometasone and formeterol

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3
Q

Which beta blockers would we be most worried about in asthmatic patients? (5)

A

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 but should still be used with caution

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4
Q

How should a spacer be cleaned?

A

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)

do not use a cloth to wipe as will create static

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5
Q

How often should a spacer be replaced?

A

Every 6-12 months

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6
Q

When would nebuliser adrenaline or budesonide be needed?

A

Child with severe croup

Not severe: oral beclometasone or prednisolone usually used

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7
Q

When should nebulisers be considered in long term management of COPD or asthma?

A

Remains breathless after two weeks of correctly using optimal therapy

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8
Q

What proportion of nebulised drug will reach lungs?

A

10-30%

Diluent usually used in nebulisers: NaCl 0.9%

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9
Q

What ages are spacers recommended in children?

A

Up till the age of 5 for bronchodilators (SABA, LABA)

Ages 5-15 for ICS

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10
Q

What is the standard length of treatment with steroids for an asthma attack? Does this differ in children?

A

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

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11
Q

In what degree of asthma attack should we consider the use of high flow oxygen?

A

If it’s severe

Use SABA (e.g. Salbutamol) nebs plus high flow oxygen

Only SABA nebs needed if moderate

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12
Q

If oxygen, SABA and prednisolone are not sufficient for an asthma attack what can be considered?

A

Ipratropium bromide
IV aminophylline
Magnesium sulphate

If an attack is LIFE-THREATENING: immediately give ipratropium (don’t wait to see if response is poor)

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13
Q

Which patients are most likely to benefit from an aminophylline infusion in an asthma attack?

A

Those that have been taking theophylline oral

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14
Q

What is step 1 of the Asthma guidelines When should a patient be moved on to step 2?

A

PRN SABAs

Move up if needed more than TWICE a week or woken up once per week

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15
Q

What is step 2 of the asthma guidelines ?

A

SABA PRN + standard dose of ICS Recommended starting dose for adults: 400mcg beclometasone daily Do not go over 800 mcg daily

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16
Q

What is step 3 of the NICE asthma guidelines

A

Add a LTRA in addition to ICS and review in 4-8 weeks

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17
Q

Step 4 of the asthma treatment guidelines?

A

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and an LTRA as maintenance therapy, offer a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA treatment as follows:

discuss with the person whether or not to continue LTRA treatment

take into account the degree of response to LTRA treatment.

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18
Q

Step 5 of the asthma treatment guidelines?

A

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a LABA, with or without an LTRA, as maintenance therapy, offer to change the person’s ICS and LABA maintenance therapy to a MART regimen with a low maintenance ICS dose.

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19
Q

Stepping down: How often should asthma treatment be reviewed?

A

Every 3 months

Consider reducing ICS by 25-50% every 3 months

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20
Q

What age of child do the asthma guidelines become different?

A

NICE:

under 5

5-16

17+

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21
Q

Child under 5: asthma guidelines step 1?

A

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)

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22
Q

Child under 5: asthma guidelines step 2?

A

8 week trial of ICS

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23
Q

Child under 5: asthma guidelines step 3?

A

SABA PRN Plus ICS Plus montelukast

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24
Q

Child under 5: asthma guidelines step 4?

A

Refer to specialist

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25
Q

What is standard dose ICS for adults?

A

Equivalent to beclometasone 400-800 mcg daily (200-400mcg BD)

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26
Q

What is standard dose ICS for children aged under 12?

A

200-400 mcg beclometasone daily (100-200mcg BD)

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27
Q

What is high dose ICS for adults?

A

800-2000mcg daily (400-1000 mcg BD)

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28
Q

Which ICS is not recommend in children under 12?

A

Mometasone

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29
Q

What ORAL drugs used in asthma can be taken as normal in pregnancy and breast feeding? (2)

A

Prednisolone Theophylline NB: all inhaled drugs can be taken as normal too, where possible use inhaled therapy over oral therapy

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30
Q

What oxygen level are we aiming for when oxygen is given in acute exacerbation of asthma?

A

94 - 98% Remember it is lower in COPD (88-92%) due to risk of T2 respiratory failure/ higher levels of CO2 in blood

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31
Q

What are the two SABAs that are used at step 1 of asthma treatment?

A

Salbutamol Terbutaline

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32
Q

Should LABAs be used for the relief for exercise induced asthma symptoms?

A

No unless regular ICS also used

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33
Q

Which LABAs are only licensed for COPD (i.e. not also in asthma)?

A

Indacterol and Olodaterol

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34
Q

What electrolyte disturbance can result from theophylline and salbutamol use together?

A

Hypokaleamia

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35
Q

In management of acute exacerbations of asthma, which is used out of aminophylline and theophylline?

A

Aminophylline

This is just the injectable form of theophylline (it consists of theophylline plus ethylenediamine) which is 20 times more soluble (and therefore potent) than theophylline

Theophylline levels are monitored with aminophylline therapy

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36
Q

What is paradoxical bronchospasm a side effect of? (This is sudden constriction of the airways)

A

Inhaled corticosteroids

It can be prevented by using a SABA beforehand or using a DPI instead

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37
Q

How long does it take to see improvement with ICS?

A

3 - 7 days

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38
Q

What does SMART stand for? What does this mean? What inhalers are involved?

A

Symbicort maintenance and reliever therapy Symbicort contains a preventer (budesonide) and a reliever (formeterol)

It is supposed to take away the need for PRN reliever- salbutamol- as you instead use this as the reliever at an increased dose if you get symptoms of breathlessness

Other examples of MART inhalers: Duoresp spiromax (also budesonide and formoterol) Fostair (beclometasone and formoterol)

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39
Q

What age group can use the SMART regime?

A

Adults and children aged 12-18 years(Children use symbicort)

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40
Q

How does smoking effect ICS?

A

Current or previous smoking reduces the effect of ICS (as smoking is an enzyme inducer) and higher doses may be needed

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41
Q

Who are leukotriene receptor antagonists more effective in?

A

Exercise induced asthma
Those with rhinitis

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42
Q

When should Montelukast be given?

A

In the evening

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43
Q

What needs to be looked out for with the use of Leukotriene receptor antagonists (Montelukast)

A

Churg-strauss syndrome= autoimmune causing inflammation of small and medium-sized blood vesselsLook out for esonophillia, rash, worsening pulmonary symptoms, cardiac complications, peripheral neuropathy

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44
Q

Zafirlukast is cautioned in ______ disorder

drug no longer available ignore card

A

Hepatic disorders

no longer availale

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45
Q

What are sodium chromoglycate and nedocromil used in?

A

Allergic asthma

Inhaled drugs caution: these can cause paradoxical bronchospasm

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46
Q

What is Omalizumab used in?

A

It is a monoclonal antibody that binds to immunoglobulin E Used for sensitivity to inhaled allergens/ allergic asthma Churd-strauss syndrome also been associated with this drug

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47
Q

What 3 conditions can effect plasma theophylline concentration?

A

Heart failure Hepatic impairment Viral infections!

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48
Q

What electrolyte disturbance can aminophylline and theophylline cause?

A

Hypokaleamia

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49
Q

What is the target level of theophylline?

A

10 - 20 mg/ L

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50
Q

What should be monitored when giving IV Beta 2 agonists (IV salbutamol)?

A

K+ in severe asthma

Blood glucose in diabetics as can cause hyperglycaemia and DKA!!!!

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51
Q

What is the dose of salbutamol inhaler in asthma?

A

100- 200 mcg (1-2 puffs) up to 4 times a day for persistent symptoms (max 8 puffs a day)

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52
Q

What are the symptoms of Oral thrush (caused by ICS)?

A

white patches (plaques) in the mouth that can often be wiped off, leaving behind red areas that may bleed slightly

loss of taste/ unpleasant taste redness inside the mouth

cracks at the corners of the mouth

a painful, burning sensation in the mouth

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53
Q

What is step one in treating COPD (hint: PRN drugs)?

A

SABA or SAMA (Ipratropium) when required

SABA can be continued at all stages but SAMA must be discontinued if a LAMA is used (i.e. wouldn’t be using ipratropium and tiotropium together)

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54
Q

If FEV is over 50% what is the treatment plan??

A

LABA OR LAMA (tiotropium)If this fails then use LABA + ICS combination inhalerIf this fails triple therapy with all three: LABA + ICS + LAMA

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55
Q

If FEV is under 50 % what is the treatment plan?

A

LAMA alone or LABA/ ICS combination inhaler (consider LABA/ LAMA combo if ICS declined)If this fails triple therapy: LABA + ICS + LAMA

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56
Q

Name some of the LABA + ICS combination inhalers used in COPD?

A

LABA + ICS combos are commonly seen in COPD as they are indicated if FEV is over under 50 %Steroids are only licensed in COPD if given in combination inhalersSymbicort Turbohaler: Budesonide + Formoterol Seretide 500 Accuhaler: Fluticasone + SalmeterolNB: seretide MDI not licensed in COPD

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57
Q

If symptoms persist after triple therapy in COPD what should be used?

A

Theophyllin/ aminophylline Then Roflumilast

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58
Q

What duration of prednisolone is indicated for COPD exacerbations?

A

30mg daily 7 - 14 days Can be stopped abruptly as not over 3 weeks use

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59
Q

How is oxygen administered in COPD patients?

A

24-28 % through a venturi facemark to avoid hypercapnia88-92 % target

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60
Q

Why doe patients on nebulisers need to wear goggles with ipratropium nebs?!

A

Because acute closed angle GLAUCOMA can occur especially if used with nebulised salbutamol

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61
Q

What are the main side effects with anti muscarinic inhalers?

A

These are ipratropium (SAMA) and tiotropium (LAMA)Main SE’s:ARRHYTHMIAS therefore cautioned in CARDIAC DISORDERS. Also need to used with caution with drugs that cause Hypokaleamia/ hyperkaleamia as this can cause arrhythmias GLAUCOMA- Ipratropium nebs- wear goggles Antimuscarinic SEs such as dry mouth, constipation, sweating, urinary retention etc but these are more common with oral therapy.

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62
Q

What is the risk of INTRAVENOUS SHORT ACTING BETA 2 AGONISTS SUCH AS SALBUTAMOL in DIABETICS?

A

Risk of HYPERGLYCAEMIA
Also a risk of diabetic Ketoacidosis!!

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63
Q

What are the CHM warnings associated with the LABAs formoterol and salmeterol?

A

Do not prescribe alone- only add on to ICS therapy Do not initiate in rapidly deteriorating asthmaDon’t used for relief of exercise induced asthma unless regular ICS used too report symptoms of paradoxical bronchospasm

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64
Q

Clear improvement within 3 -4 weeks of ICS therapy indicates which COPD or Asthma?

A

AsthmaThis can be used to differentiate between the two

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65
Q

When is Ipratropium not allowed to be continued in COPD?

A

If patients are on a LAMA (tiotropium)

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66
Q

What is spiriva? How often is it given?

A

TiotropiumComes as either Spiriva inhalation powder (18mcg capsules) or Spiriva Respimat pressurised MDIIt is given OD (One capsule/ 2 puffs of respimat inhaler)

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67
Q

What is the role of ICS in COPD?

A

To reduce exacerbations Slight lack of evidence of ICS benefits in COPDReasonably high doses required (e.g 800mcg budesonide)Steroids only licensed in COPD if in combination inhalers

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68
Q

When should osteoporosis prophylaxis be considered with oral predinisolone use?

A

received over 3 courses of steroids lasting over 7 days in the previous 12 months All patients over 65 should receive prophylaxis

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69
Q

Chronic productive cough in COPD treatment?

A

Mucolytics:Carbocisteine/ Mecysteine

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70
Q

We know beta blockers are cautioned in asthma… but can they be given in COPD?

A

Yes… but just monitor closely monitor for broncho spasms

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71
Q

What is Aclidinium?

A

A LAMA also used in maintenance of COPD Comes as the “Genuair” inhaler- a DPI that has a little window that turns from green to red if dose is inhaled correctly

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72
Q

What is Glycopyrronium?

A

A LAMA used in COPD maintenance

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73
Q

What is Umeclidinium?

A

Another LAMA used in COPD maintenance. Comes as the Ellipta DPI - has a dose counter- also comes in a combo Ellipta inhaler: Umeclidinium with vilanterol.

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74
Q

Tiotropium is a LAMA used for maintenance of COPD but not suitable for treatment of _______

A

Acute bronchospasm

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75
Q

What is paradoxical bronchospasm?

A

paradoxical means ‘contradictory/ going against oneself’Paradoxical bronchospasm is where ICS can actually do the opposite to what they’re meant to and cause airways to constrict and breathing to get worse. This means that ICS should not be used again

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76
Q

We know salbutamol can cause potassium disturbance… a SABA… Can LABAs?

A

Yes Laba can also cause Hypokaleamia

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77
Q

When does ipratropium bromides maximal effects take place?

A

30- 60 minutes after use

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78
Q

DPIs are recommended in children over what age?

A

5 yearsHowever, between 3 and 5 years DPI can be considered if existing treatment is ineffective

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79
Q

What is the MHRA advice surrounding PMDIs?

A

Risk of airway obstruction from aspiration of loose objectsPatients should be reminded to remove the mouthpiece cover fully, shake the device and check that both the outside and inside of the mouthpiece are clear and undamaged before inhaling a dose, and to store the inhaler with the mouthpiece cover on.

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80
Q

What are the different types of inhalers?

A

DPIMDIBreath actuated

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81
Q

How should you clean spacer devices?

A

The device should be cleaned once a month by washing in mild detergent and then allowed to dry in air without rinsing; the mouthpiece should be wiped clean of detergent before use.

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82
Q

How often should spacers be replaced?

A

Every 6-12 months

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83
Q

What are the main nebulised drugs and their associated indications?

A
  • A beta 2 agonist or ipratropium bromide to a patient with an acute exacerbation of asthma or of chronic obstructive pulmonary disease- A beta 2 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 inhalational devices- An antibiotic (such as colistimethate sodium) or a mucolytic to a patient with cystic fibrosis- Budesonide or adrenaline/epinephrine to a child with severe croup- Pentamidine isetionate for the prophylaxis and treatment of pneumocystis pneumonia.
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84
Q

Why would you want to avoid high dose ICS in children?

A

Associated with adrenal suppression, growth impairment and reduced bone mineral density.

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85
Q

According to BTS guidelines, what should be prescribed if a patient has been diagnosed with asthma?How does this differ in children?

A

SABAConsider monitored initiation with low dose ICSStill use SABA but can start with a VERY low dose of ICSIf the patient is still getting symptomatic, short-lived wheezes, this ICS should be used as a regular preventer

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86
Q

According to BTS and NICE guidelines, in what situations would a patient need a regular preventor?

A
  • If they are using 3 or more doses of their SABA a week- Symptomatic three times a week or more, - Waking at night due to asthma symptoms at least once a week. - Had asthma attack in the last 2 years
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87
Q

BTS asthma guidelines in adults:If a patient is on a regular low dose ICS and SABA yet symptoms are not being controlled, what would the next step up be?

A

Add inhaled LABA (normally as a combination inhaler with ICS)

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88
Q

BTS asthma guidelines in adults:Patient’s regular meds:Low dose ICS and LABA combinationSABAIf no response to the LABA, what would the next step be?

A

Stop LABA and increase dose of ICS

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89
Q

BTS asthma guidelines in adults:Patient’s regular meds:Low dose ICS and LABA combinationSABAIf the patient is benefitting from the LABA yet symptoms are still not being controlled, what would the next step be?

A

Continue LABA and increase ICS to medium doseAt this point you can also consider trials of:LTRAS-R TheophyllineLAMA

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90
Q

BTS asthma guidelines in adults:Patient’s regular meds:Medium dose ICS and LABA combinationSABAHas had a trial of LAMA/LTRA/SR-TheophyllineIf a patient is still symptomatic, what would the next step be?

A

High dose therapiesConsider trial of:High dose ICSAddition of 4th drug e.g. LTRA, SR-Theophylline, beta agonist tablet, LAMARefer to specialist care

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91
Q

BTS asthma guidelines in adults:After high dose therapies, what would the next step be?

A

Continuous or frequent use of oral steroids Use daily steroid tablet in the lowest dose providing adequate control Maintain high dose ICS Refer to specialist care

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92
Q

In an asthma attack, if a patient required nebulisers, is this driven by air or oxygen?

A

Oxygen

93
Q

For asthmatic children under 5 years, what type of inhaler is recommended for bronchodilator therapy?

A

Pressurised metered-dose inhaler and spacer device, with a facemask if necessary

94
Q

For asthmatic children under 5 years, what type of inhaler is recommended for corticosteroid therapy?

A

Pressurised metered-dose inhaler and spacer device, with a facemask if necessary

95
Q

For asthmatic children between 5 and 15, what type of inhaler is recommended for corticosteroid therapy?

A

Pressurised metered-dose inhaler and spacer device

96
Q

For asthmatic children between 5 and 15, what type(s) of inhalers is recommended for bronchodilator therapy?

A

Consider a wider range of inhalers- not just PMDIsAll down to what suits the patient and compliance

97
Q

What is the target peak expiratory flow in asthma?

A

> 80%

98
Q
  1. BTS asthma guidelines recommend that ICS should be initially taken how many times a day?2 .What steroid is the exception to this?
A
  1. Twice a day(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)2. Ciclesonide should be taken only once daily initially (only twice daily in severe asthma)
99
Q

True or false:BTS recommend that inhalers do not need to be prescribed by brand

A

FalseThey should be prescribed by brand

100
Q

How long should be the initial trial of an ICS be in a child under 5?After this trial, in what situation would you continue the ICS?

A

8 weeks and then review to see if it has benefittedIf they had another exacerbation within 4 weeks of stopping, then continue

101
Q

When would you consider decreasing maintenance therapy for asthma?What is the recommended dose reduction for ICS at a time and how often?

A

When a patient’s asthma has been controlled with their current maintenance therapy for at least three monthsReduction of 25-50% ICS dose every 3 months

102
Q

Can inhaled corticosteroids be used during pregnancy for asthma?

A

Yes

103
Q

Can oral corticosteroids be used during pregnancy for asthma?

A

Yes

104
Q

What is 1st line for acute asthma in adults?How does the administration route differ with non-life threatening vs life threatening?

A

High dose inhaled SABA (salbutamol or terbutaline) and oral prednisolone once daily for at least 5 days or until recovery Non-life threatening - PMDI recommendedLife-threatening - oxygen driver nebuliser recommended

105
Q

In what situation would you use IV beta 2 agonists for acute asthma in adults?

A

If inhaled therapy cannot be used reliably

106
Q

In severe acute adult asthma, if the patient has poor response to nebulised SABA, what can be added?

A

Nebulised ipratropium

107
Q

What kind of drug is ipratropium?

A

SAMA

108
Q

What kind of drug is tiotropium?

A

LAMA

109
Q

Are brands of ICS interchangeable?

A

No- all contain different doses of different steroids

110
Q

Is LABA monotherapy recommended in asthma?

A

NoShould always have an ICS or combination inhaler with ICSAssociated with ADRs and death

111
Q

What type of inhaler is an accuhaler?

A

DPI

112
Q

What type of inhaler is an evohaler?

A

MDI

113
Q

What is a disadvantage of a DPI?

A

Breath actuated, need to have respiratory effort for itIf not, MDI is more appropriate

114
Q

What is the only LAMA licensed for asthma?

A

Tiotropium

115
Q

Which tiotropium inhaler is licensed in asthma?

A

Spiriva Respimat 2.5 mcg (2 puffs OD)The following are only licensed in COPD:Braltus 10 microgram capsules (Zonda inhaler)Spiriva 18 microgram capsules (Handihaler)

116
Q

What is the only Seretide licensed in COPD?

A

Seretide 500 AccuhalerThe lower dose Seretide accuhalers and the evohalers are not licensed(But all Seretides are licensed for asthma)

117
Q

In children of all ages, what do you give for acute asthma?

A

Inhaled SABAOnce daily dose of oral prednisolone, usually for 3 days or until recovery

118
Q

In children of all ages in acute asthma, if an inhaled SABA is not sufficient, what else can be given?

A

Nebulised ipratropium combined with SABA

119
Q

BTS guidelines:In paediatric asthmatic patients, if they are on a SABA and a very low dose ICS, what would the next step be?

A

<5 years: Add LTRA5 years and above: Add inhaled LABA

120
Q

BTS guidelines for paediatric asthmaIf a patient is on:SABAVery low dose ICS LABAHowever there is no response to the LABA, what would the next step be?

A

Stop LABA and increase ICS to a low dose

121
Q

BTS guidelines for paediatric asthmaIf a patient is on:SABAVery low dose ICS LABA/LTRAIf there is benefit from the LABA but control still inadequate, what would the next step be?

A

Continue LABA but increase ICS to a low doseAlso consider trial of other therapy e.g. LTRA if not on already

122
Q

BTS guidelines for paediatric asthmaIf a patient is on:SABALow dose ICS LABALTRAWhat would the next step be?

A

Refer for specialist careConsider trials of medium dose ICSAddition of 4th drug e.g. SR-theophyllineIf these do not work, may need daily steroid tablet at lowest dose providing control

123
Q

How would you treat mild croup?

A

Mostly self-limitingSingle dose of corticosteroid e.g. dexamethasone may be helpful

124
Q

How would you manage severe croup?

A

Hospital admissionSteroid- dexamethasone or prednisolone before admissionIn hospital- give oral/IV dexamethasone or nebulised budesonideIf this does not provide control- nebulised adrenaline

125
Q

If someone needed oxygen therapy, in what group of patients would you give low concentration rather than high?

A

COPDCFOverdose of opioid and benzosLung scarring by TB

126
Q

Theophylline is given as an injection as what drug and why?

A

Aminophylline, a mixture of theophylline with ethylenediamine, which is 20 times more soluble than theophylline alone

127
Q

Beta agonists can cause deficiency in what electrolyte?In what group of patients would this be a particular caution?

A

Can cause hypokalaemia if high doses usedSevere asthma- may be potentiated by concomitant treatment with theophylline, corticosteroids

128
Q

What are the common side effects of beta agonists?

A

ArrythmiasDizzinessHeadacheHypokalaemia (high doses) Tremor PalpitationsHyperglycaemia - needs monitoring in diabetics

129
Q

What is the important safety info on the use of formoterol and salmeterol in asthma?

A
  • Be added only if regular use of standard-dose inhaled corticosteroids has failed to control asthma adequately;- not be initiated in patients with rapidly deteriorating asthma;- be introduced at a low dose and the effect properly monitored before considering dose increase;- be discontinued in the absence of benefit;not be used for the relief of exercise-induced asthma symptoms unless regular inhaled corticosteroids are also used;- be reviewed as clinically appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved.
130
Q

What combination is in a Fostair inhaler?

A

Beclometasone and formoterol

131
Q

What is a caution in nebulised ipratropium? (what can it cause)?How can the risk of this be reduced?

A

Acute angle closed glaucoma, especially in combination with nebulised salbutamol. Need to protect the patient’s eyes from nebulised drug or powder. If nebulised iptratropium is needed in a glaucoma patient, they need a very tight fitting nebs mask ALSO cautioned in enlarged prostate and bladder outflow obstruction

132
Q

What is the MHRA advise regarding Braltus tiotropium inhalation capsules?

A

Reports of patients who have inhaled a Braltus capsule from the mouthpiece into the back of the throat, resulting in coughing and risking aspiration or airway obstruction

133
Q

What combination is in a Relvar Ellipta (92/22)?

A

ICS LAMAFluticasone and vilanterol

134
Q

What combination is in a Seretide?

A

ICS LAMAFluticasone and salmeterol

135
Q

What combination is in a Symbicort Turbohaler?

A

ICS LAMABudesonide and formoterol

136
Q

What combination is in a Flutiform MDI?

A

ICS LAMAFluticasone and formoterol

137
Q

What are the LABAs licensed in asthma?

A

SalmeterolFormoterolIndacaterolVilanterol

138
Q

If a patient is on the following:SABASAMAICSLABAAnd they are prescribed a LAMA, what medicine should be stopped?

A

Their SAMA

139
Q

What LAMAs are licensed in asthma?

A

Tiotropium Spiriva Respimat 2.5 micrograms (dose 2 puffs -5 micrograms)

140
Q

What SABAs are licensed in asthma?

A

SalbutamolTerbutaline

141
Q

What ICS inhalers are licensed in asthma?

A

Clenil (beclomethasone)Pulmicort (budesonide)Flixotide (fluticasone)

142
Q

What steroid is in Clenil?

A

Beclomethasone

143
Q

What steroid is in Pulmicort?

A

Budesonide

144
Q

What steroid is in Flixotide?

A

Fluticasone

145
Q

What ICS/LABA is licensed in asthma?

A

Relvar ElliptaSeretide and SirduplaSymbicort and DuorespFlutiformFostair

146
Q

What LAMAs are licensed in COPD?

A

GlycopyyroniumTiotropiumAclidiniumUmeclidiniumTiotropium

147
Q

What combination is Ultibro Breezhaler?

A

LAMA LABAGlycopyrronium/indacaterol

148
Q

What combination is Anoro Ellipta?

A

LAMA LABAUmeclidium/vilanterol

149
Q

What combination is Duaklir Genuair?

A

LAMA LABAAclidinium/formoterol

150
Q

What combination is Spiolto Respimat?

A

Tiotropium/Olodaterol

151
Q

True or false:ICS monotherapy is recommended in COPD patients

A

False - always prescribe in combination with LABACan cause pneumonia, increased ADRs and increased mortality

152
Q

What is the difference between how to take MDI vs DPI?

A

MDI - slow and steadyDPI - fast and deep

153
Q

What are the side effects of inhaled antimuscarinics (SAMA and LAMA)?

A

Dry mouth, headaches, nausea, arrythmias, nose bleeds

154
Q

What is a contraindication to beta agonists?Hint- pregnancy

A

Severe pre-eclampsia

155
Q

What LABAs are licensed in COPD?

A

FormoterolSalmeterolIndacaterolOlodaterol

156
Q

What is the MHRA advice surrounding corticosteroids?

A

Rare risk of central chorioretinopathy with local and systemic administrationPatients should report any blurred vision/disturbances

157
Q

What are the common side effects of ICS?

A
  • Oral thrush- Altered voice- Cushing’s syndrone- Epistaxis - Throat irritation- Bronchospasm
158
Q

What monitoring requirement is needed in children on regular ICS?

A

Annual height and weight

159
Q

What is the important safety information surrounding beclometasone inhalers Qvar and Clenil?

A

They are not interchangeable as Qvar is more potentNeeds to be prescribed by brand

160
Q

Is Qvar or Clenil beclometasone inhaler more potent?

A

QvarHas extra fine particles and is approx twice as more potent as Clenil

161
Q
  1. When switching a patient with well controlled asthma from a 200 mcg Clenil to a Qvar, what starting dose should you start with?2. How does this differ if the patient has poor control asthma and the patient is on 100 mcg Clenil?
A
  1. Start with 100 mcg Qvar2. Same dose as Clenil- 100 mcg
162
Q

Are Clenil and Qvar inhalers licensed in COPD?

A

No- but beclometasone is licensed if in combination with formoterol (+/- glycopyrronium)Beclometasone and formoterol - FostairBeclometasone and formoterol and glycopyrronium - Trimbow

163
Q

What is the Fostair 100/6 (including nexthaler) licensed for?

A

COPD and asthma

164
Q

What is the Fostair 200/6 (including nexthaler) licensed for?

A

Asthma onlyNot COPD

165
Q

True or false:Only the higher strength Fostair (200/6) is licensed in COPD

A

FalseIt is only the 100/6 that is licensed

166
Q

What is the beclometasone (non-extra fine particles) equivalent of 100mcg Fostair (extra fine particles)?

A

250 mcg Fostair is more potent as it comtains extra fine particles

167
Q

What combination is a Trimbow inhaler?

A

Beclometasone and formoterol and glycopyrronium

168
Q

What is Trimbow licensed in?

A

COPD only

169
Q

True or false:Symbicort 100/6 is licensed in COPD

A

FalseThose licensed in COPD:200/6400/12

170
Q

Is Flutiform licensed in COPD?

A

No

171
Q

What is Trelegy licensed in?

A

COPD only

172
Q

What combination is Trelegy?

A

Fluticasone, umeclidinium and vilanterol

173
Q

Are any inhalers just containing ICS licensed in COPD?

A

NoRecommended to prescribe ICS/LABA or trio inhaler as ICS monotherapy not recommended in COPD

174
Q

What is a rare but serious side effect of montelukast?

A

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome - a disorder marked by blood vessel inflammation) Has occurred very rarely in association with the use of montelukast; in many of the reported cases the reaction followed the reduction or withdrawal of oral corticosteroid therapy. Prescribers should be alert to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, or peripheral neuropathy.

175
Q

What are the side effects of aminophylline?

A

Arrythmia (more common if IV given too rapidly)HeadacheNauseaSeizure (more common if IV given too rapidly)May potentiate hypokalaemia in beta 2 agonist therapy

176
Q

With IV aminophylline, when should a blood sample be taken?

A

4-6 hours after starting treatment

177
Q

What is the ideal plasma concentration for theophylline?

A

10-20 mg/L - above this can lead to severe side effects

178
Q

When would you measure plasma theophylline levels in a) starting oral therapy and b) after a dose adjustment?How many hours after an oral dose?

A

Measured 5 days after starting oral treatment and at least 3 days after any dose adjustment. 4-6 hours after

179
Q

How does smoking interact with theophylline and how does this affect the dose needed?

A

Smoking can increase theophylline clearance and increased doses of theophylline are therefore required

180
Q

What is the MHRA advice surrounding OTC chlorphenamine in children?

A

Children under 6 years should not be given over-the-counter cough and cold medicines containing chlorphenamine

181
Q

What is the MHRA advice surrounding hydroxyzine (sedating antihistamine)?

A

QT prolongation

182
Q

What is the MHRA advice surrounding OTC promethazine in children?

A

Children under 6 years should not be given over-the-counter cough and cold medicines containing promethazine

183
Q

What drug class do you use to treat hereditary angiodema?

A

C1 esterase inhibitor

184
Q

What is the 1st line mucolytic in CF?What can be added if inadequate response?

A

Dornase alfaHypertonic sodium chloride

185
Q

What is the MHRA advice surrounding OTC pholcodine in children?

A

Children under 6 years should not be given over-the-counter cough and cold medicines containing pholcodine6-12 years- if needed, restrict to max 5 days

186
Q

What are the symptoms of theophylline toxicity?

A

Vomiting, and vomiting up blood AgitationRestlessessDilated pupilsSinus tachycardiaHyperglycaemia ConvulsionsVentricular arrhythmias Hypokalaemia

187
Q

Should theophylline be prescribed by brand?

A

Yes as rate of absorption can vary between brands

188
Q

How does theophylline interact with quinolones?

A

Increased risk of convulsions

189
Q

How does theophylline interact with St John’s Wort?

A

Theophylline concentration reduced by St John’s Wort (enzyme inducer)

190
Q

How does theophylline interact with rifampicin?

A

Theophylline concentration reduced by rifampicin

191
Q

How does theophylline interact with cimetidine?

A

Theophylline concentration increased by cimetidine

192
Q

How does theophylline interact with fluconazole?

A

Theophylline concentration increased by fluconazole

193
Q

How does theophylline interact with disulfiram?

A

Metabolism of theophylline is inhibited by disulfiram and therefore there is an increased risk of theophylline toxicity (hyperglycaemia, dilated pupils and haematemesis)

194
Q

What type of inhaler is a Turbohaler?

A

DPI

195
Q

What is the difference in Fostair Nexthaler and Fostair inhaler?

A

Nexthaler- DPIFostair normal - pMDI

196
Q

How do you calculate pack years?

A

(Number of cigs smoked a day/20) x number of years smoked

197
Q

When should you refer a COPD patient for pulmonary rehabilitation?

A

If they are functionally disabled by COPD (usually Medical Research Council (MRC) dyspnoea scale grade 3 or above)

198
Q

What is the purpose of pulmonary rehab for COPD patients?

A
  • Can improve quality of life, increase exercise capacity safely and effectively, and reduce breathlessness.- Programmes usually comprise 2–3 sessions/week and last for 6–12 weeks.- Pulmonary rehabilitation should involve physical training; disease education; and nutritional, psychological, and behavioural interventions tailored to the person’s needs.
199
Q

Long term oxygen therapy prolongs life in COPD patients. How many hours a day at least must they be on oxygen?

A

15 hours

200
Q

True or false:In COPD, if a patient is regularly using a SAMA 4 times a day, a LAMA should be offered instead

A

TRUE

201
Q

What class of drug is bambuterol?What formulation does it come in?

A

LABATablet

202
Q

What age is QVAR inhalers licensed in?

A

12 years

203
Q

What is the adrenaline dose in anaphylaxis in:i) Children < 6 yearsii) Child 6-12 yearsiii) > 12 years and adults

A

IM injection (1 in 1000 solution) repeated every 5 minutes if necessaryAdminister into thigh i) Children < 6 years: 150 microgramsii) Child 6-12 years: 300 microgramsiii) > 12 years and adults: 500 micrograms (For EpiPen brand it is 300 micrograms)

204
Q

Patients on what medicine may not respond to adrenaline?What could be an alternative

A

Beta blockersIV salbutamol could be an alternative

205
Q

What is the MHRA advice with adrenaline auto-injectors?

A

It is recommend that 2 adrenaline auto-injectors are prescribed, which patients should carry BOTH at all times.Check expiry dates

206
Q

What time of the day should LTRA be taken?

A

Evening

207
Q

A patient requesting more than how many SABAs a month prompts a referral?

A

> 1 a month

208
Q

True or false:Lung function measurements are used to guide asthma treatment of all ages

A

FalseNot reliable in <5 years old

209
Q

Are Ellipta inhalers DPI or MDI?

A

DPI

210
Q

Can Clenil Modulite MDI be used in children?Is there any cut off age?

A

Yes - all ages

211
Q

What type of inhaler is Clenil Modulite?

A

MDI

212
Q

What type of inhaler is an Easyhaler?

A

DPI

213
Q

What age is a a Beclometasone Easyhaler licensed in?

A

> 12 years

214
Q

Can a Beclometasone Easyhaler be used in a 7 year old?

A

No >12 years only

215
Q

What age is a Qvar inhaler licensed in?

A

> 12 years

216
Q

What type of inhaler is an Autohaler?

A

MDI

217
Q

What age is Fostair licensed in?

A

> 18 years

218
Q

What age is Pulmicort turbohaler licensed in?

A

5 years and over

219
Q

What age is Symbicort for maintenance therapy licensed in?

A

6 years and over

220
Q

What age is Symbicort for maintenance AND reliever therapy licensed in?

A

12 years and over

221
Q

What is the only strength Seretide Evohaler licensed in children and what is the cut off age?

A

25/50 licensed in children from 4 years

222
Q

What are the 3 strengths of Seretide Evohaler?

A

25/5025/12525/250

223
Q

What are the 3 Strengths of Seretide Accuhaler?

A

50/10050/25050/500

224
Q

What is the only strength Seretide Accuhaler licensed in children and what is the cut off age?

A

50/100 licensed in children from 4 years

225
Q

What are the 3 inhalers licensed in MART therapy and the ages they are licensed in?

A

Fostair 100/6 for 18 years + (This is NOT the nexthaler)Symbicort 100/6 and 200/6 for 12 years +Duoresp Spiromax 160/4.5 for 18 years +

226
Q

What is the inhaler that is shaped like an egg?

A

Spiriva Handihaler 18 micrograms tiotropium

227
Q

What does a whistling when a patient is using their inhaler mean?

A

They are breathing in too fast

228
Q

When should you issue a steroid card to a patient on an ICS?

A

If on high dose ICS

My Pham Notes (22 decks)

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