Chapter 3: Respiratory system Flashcards
How should patients used DPI inhalers?
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
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 affected- has extra fine particles (beclometasone and formeterol
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 but should still be used with caution
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)
do not use a cloth to wipe as will create static
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, LABA)
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
In what degree of asthma attack should we consider the use of high flow oxygen?
If it’s severe
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)
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?
PRN SABAs
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
What is step 3 of the NICE asthma guidelines
Add a LTRA in addition to ICS and review in 4-8 weeks
Step 4 of the asthma treatment guidelines?
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.
Step 5 of the asthma treatment guidelines?
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.
Stepping down: How often should asthma treatment be reviewed?
Every 3 months
Consider reducing ICS by 25-50% every 3 months
What age of child do the asthma guidelines become different?
NICE:
under 5
5-16
17+
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)
Child under 5: asthma guidelines step 2?
8 week trial of ICS
Child under 5: asthma guidelines step 3?
SABA PRN Plus ICS Plus montelukast
Child under 5: asthma guidelines step 4?
Refer to specialist
What is standard dose ICS for adults?
Equivalent to beclometasone 400-800 mcg daily (200-400mcg BD)
What is standard dose ICS for children aged under 12?
200-400 mcg beclometasone daily (100-200mcg BD)
What is high dose ICS for adults?
800-2000mcg daily (400-1000 mcg BD)
Which ICS is not recommend in children under 12?
Mometasone
What ORAL drugs used in asthma can be taken as normal in pregnancy and breast feeding? (2)
Prednisolone Theophylline NB: all inhaled drugs can be taken as normal too, where possible use inhaled therapy over oral therapy
What oxygen level are we aiming for when oxygen is given in acute exacerbation of asthma?
94 - 98% Remember it is lower in COPD (88-92%) due to risk of T2 respiratory failure/ higher levels of CO2 in blood
What are the two SABAs that are used at step 1 of asthma treatment?
Salbutamol Terbutaline
Should LABAs be used for the relief for exercise induced asthma symptoms?
No unless regular ICS also used
Which LABAs are only licensed for COPD (i.e. not also in asthma)?
Indacterol and Olodaterol
What electrolyte disturbance can result from theophylline and salbutamol use together?
Hypokaleamia
In management of acute exacerbations of asthma, which is used out of aminophylline and theophylline?
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
What is paradoxical bronchospasm a side effect of? (This is sudden constriction of the airways)
Inhaled corticosteroids
It can be prevented by using a SABA beforehand or using a DPI instead
How long does it take to see improvement with ICS?
3 - 7 days
What does SMART stand for? What does this mean? What inhalers are involved?
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)
What age group can use the SMART regime?
Adults and children aged 12-18 years(Children use symbicort)
How does smoking effect ICS?
Current or previous smoking reduces the effect of ICS (as smoking is an enzyme inducer) and higher doses may be needed
Who are leukotriene receptor antagonists more effective in?
Exercise induced asthma
Those with rhinitis
When should Montelukast be given?
In the evening
What needs to be looked out for with the use of Leukotriene receptor antagonists (Montelukast)
Churg-strauss syndrome= autoimmune causing inflammation of small and medium-sized blood vesselsLook out for esonophillia, rash, worsening pulmonary symptoms, cardiac complications, peripheral neuropathy
Zafirlukast is cautioned in ______ disorder
drug no longer available ignore card
Hepatic disorders
no longer availale
What are sodium chromoglycate and nedocromil used in?
Allergic asthma
Inhaled drugs caution: these can cause paradoxical bronchospasm
What is Omalizumab used in?
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
What 3 conditions can effect plasma theophylline concentration?
Heart failure Hepatic impairment Viral infections!
What electrolyte disturbance can aminophylline and theophylline cause?
Hypokaleamia
What is the target level of theophylline?
10 - 20 mg/ L
What should be monitored when giving IV Beta 2 agonists (IV salbutamol)?
K+ in severe asthma
Blood glucose in diabetics as can cause hyperglycaemia and DKA!!!!
What is the dose of salbutamol inhaler in asthma?
100- 200 mcg (1-2 puffs) up to 4 times a day for persistent symptoms (max 8 puffs a day)
What are the symptoms of Oral thrush (caused by ICS)?
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
What is step one in treating COPD (hint: PRN drugs)?
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)
If FEV is over 50% what is the treatment plan??
LABA OR LAMA (tiotropium)If this fails then use LABA + ICS combination inhalerIf this fails triple therapy with all three: LABA + ICS + LAMA
If FEV is under 50 % what is the treatment plan?
LAMA alone or LABA/ ICS combination inhaler (consider LABA/ LAMA combo if ICS declined)If this fails triple therapy: LABA + ICS + LAMA
Name some of the LABA + ICS combination inhalers used in COPD?
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
If symptoms persist after triple therapy in COPD what should be used?
Theophyllin/ aminophylline Then Roflumilast
What duration of prednisolone is indicated for COPD exacerbations?
30mg daily 7 - 14 days Can be stopped abruptly as not over 3 weeks use
How is oxygen administered in COPD patients?
24-28 % through a venturi facemark to avoid hypercapnia88-92 % target
Why doe patients on nebulisers need to wear goggles with ipratropium nebs?!
Because acute closed angle GLAUCOMA can occur especially if used with nebulised salbutamol
What are the main side effects with anti muscarinic inhalers?
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.
What is the risk of INTRAVENOUS SHORT ACTING BETA 2 AGONISTS SUCH AS SALBUTAMOL in DIABETICS?
Risk of HYPERGLYCAEMIAAlso a risk of diabetic Ketoacidosis!!
What are the CHM warnings associated with the LABAs formoterol and salmeterol?
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
Clear improvement within 3 -4 weeks of ICS therapy indicates which COPD or Asthma?
AsthmaThis can be used to differentiate between the two
When is Ipratropium not allowed to be continued in COPD?
If patients are on a LAMA (tiotropium)
What is spiriva? How often is it given?
TiotropiumComes as either Spiriva inhalation powder (18mcg capsules) or Spiriva Respimat pressurised MDIIt is given OD (One capsule/ 2 puffs of respimat inhaler)
What is the role of ICS in COPD?
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
When should osteoporosis prophylaxis be considered with oral predinisolone use?
received over 3 courses of steroids lasting over 7 days in the previous 12 months All patients over 65 should receive prophylaxis
Chronic productive cough in COPD treatment?
Mucolytics:Carbocisteine/ Mecysteine
We know beta blockers are cautioned in asthma… but can they be given in COPD?
Yes… but just monitor closely monitor for broncho spasms
What is Aclidinium?
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
What is Glycopyrronium?
A LAMA used in COPD maintenance
What is Umeclidinium?
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.
Tiotropium is a LAMA used for maintenance of COPD but not suitable for treatment of _______
Acute bronchospasm
What is paradoxical bronchospasm?
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
We know salbutamol can cause potassium disturbance… a SABA… Can LABAs?
Yes Laba can also cause Hypokaleamia
When does ipratropium bromides maximal effects take place?
30- 60 minutes after use
DPIs are recommended in children over what age?
5 yearsHowever, between 3 and 5 years DPI can be considered if existing treatment is ineffective
What is the MHRA advice surrounding PMDIs?
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.
What are the different types of inhalers?
DPIMDIBreath actuated
How should you clean spacer devices?
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.
How often should spacers be replaced?
Every 6-12 months
What are the main nebulised drugs and their associated indications?
- 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.
Why would you want to avoid high dose ICS in children?
Associated with adrenal suppression, growth impairment and reduced bone mineral density.
According to BTS guidelines, what should be prescribed if a patient has been diagnosed with asthma?How does this differ in children?
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
According to BTS and NICE guidelines, in what situations would a patient need a regular preventor?
- 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
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?
Add inhaled LABA (normally as a combination inhaler with ICS)
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?
Stop LABA and increase dose of ICS
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?
Continue LABA and increase ICS to medium doseAt this point you can also consider trials of:LTRAS-R TheophyllineLAMA
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?
High dose therapiesConsider trial of:High dose ICSAddition of 4th drug e.g. LTRA, SR-Theophylline, beta agonist tablet, LAMARefer to specialist care
BTS asthma guidelines in adults:After high dose therapies, what would the next step be?
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