Chapter 3: Respiratory system Flashcards
1
Q
DPIs are recommended in children over what age?
A
5 years
However, between 3 and 5 years DPI can be considered if existing treatment is ineffective
2
Q
What is the MHRA advice surrounding PMDIs?
A
Risk of airway obstruction from aspiration of loose objects
Patients 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.
3
Q
What are the different types of inhalers?
A
DPI
MDI
Breath actuated
4
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.
5
Q
How often should spacers be replaced?
A
Every 6-12 months
6
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.
7
Q
Why would you want to avoid high dose ICS in children?
A
Associated with adrenal suppression, growth impairment and reduced bone mineral density.
8
Q
According to BTS guidelines, what should be prescribed if a patient has been diagnosed with asthma?
How does this differ in children?
A
SABA
Consider monitored initiation with low dose ICS
Still use SABA but can start with a VERY low dose of ICS
If the patient is still getting symptomatic, short-lived wheezes, this ICS should be used as a regular preventer
9
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
10
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)
11
Q
BTS asthma guidelines in adults:
Patient’s regular meds:
Low dose ICS and LABA combination
SABA
If no response to the LABA, what would the next step be?
A
Stop LABA and increase dose of ICS
12
Q
BTS asthma guidelines in adults:
Patient’s regular meds:
Low dose ICS and LABA combination
SABA
If 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 dose
At this point you can also consider trials of:
LTRA
S-R Theophylline
LAMA
13
Q
BTS asthma guidelines in adults:
Patient’s regular meds:
Medium dose ICS and LABA combination
SABA
Has had a trial of LAMA/LTRA/SR-Theophylline
If a patient is still symptomatic, what would the next step be?
A
High dose therapies
Consider trial of:
High dose ICS
Addition of 4th drug e.g. LTRA, SR-Theophylline, beta agonist tablet, LAMA
Refer to specialist care
14
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
15
Q
In an asthma attack, if a patient required nebulisers, is this driven by air or oxygen?
A
Oxygen
16
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
17
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
18
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
19
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 PMDIs
All down to what suits the patient and compliance
20
Q
What is the target peak expiratory flow in asthma?
A
> 80%
21
Q
- BTS asthma guidelines recommend that ICS should be initially taken how many times a day?
2 .What steroid is the exception to this?
A
- 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)
- Ciclesonide should be taken only once daily initially (only twice daily in severe asthma)
22
Q
True or false:
BTS recommend that inhalers do not need to be prescribed by brand
A
False
They should be prescribed by brand
23
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 benefitted
If they had another exacerbation within 4 weeks of stopping, then continue
24
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 months
Reduction of 25-50% ICS dose every 3 months
25
Can inhaled corticosteroids be used during pregnancy for asthma?
Yes
26
Can oral corticosteroids be used during pregnancy for asthma?
Yes
27
What is 1st line for acute asthma in adults?
How does the administration route differ with non-life threatening vs life threatening?
High dose inhaled SABA (salbutamol or terbutaline) and oral prednisolone once daily for at least 5 days or until recovery
Non-life threatening - PMDI recommended
Life-threatening - oxygen driver nebuliser recommended
28
In what situation would you use IV beta 2 agonists for acute asthma in adults?
If inhaled therapy cannot be used reliably
29
In severe acute adult asthma, if the patient has poor response to nebulised SABA, what can be added?
Nebulised ipratropium
30
What kind of drug is ipratropium?
SAMA
31
What kind of drug is tiotropium?
LAMA
32
Are brands of ICS interchangeable?
No- all contain different doses of different steroids
33
Is LABA monotherapy recommended in asthma?
No
Should always have an ICS or combination inhaler with ICS
Associated with ADRs and death
34
What type of inhaler is an accuhaler?
DPI
35
What type of inhaler is an evohaler?
MDI
36
What is a disadvantage of a DPI?
Breath actuated, need to have respiratory effort for it
| If not, MDI is more appropriate
37
What is the only LAMA licensed for asthma?
Tiotropium
38
Which tiotropium inhaler is licensed in asthma?
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)
39
What is the only Seretide licensed in COPD?
Seretide 500 Accuhaler
The lower dose Seretide accuhalers and the evohalers are not licensed
(But all Seretides are licensed for asthma)
40
In children of all ages, what do you give for acute asthma?
Inhaled SABA
| Once daily dose of oral prednisolone, usually for 3 days or until recovery
41
In children of all ages in acute asthma, if an inhaled SABA is not sufficient, what else can be given?
Nebulised ipratropium combined with SABA
42
BTS guidelines:
| In paediatric asthmatic patients, if they are on a SABA and a very low dose ICS, what would the next step be?
<5 years: Add LTRA
5 years and above: Add inhaled LABA
43
BTS guidelines for paediatric asthma
If a patient is on:
SABA
Very low dose ICS
LABA
However there is no response to the LABA, what would the next step be?
Stop LABA and increase ICS to a low dose
44
BTS guidelines for paediatric asthma
If a patient is on:
SABA
Very low dose ICS
LABA/LTRA
If there is benefit from the LABA but control still inadequate, what would the next step be?
Continue LABA but increase ICS to a low dose
Also consider trial of other therapy e.g. LTRA if not on already
45
BTS guidelines for paediatric asthma
```
If a patient is on:
SABA
Low dose ICS
LABA
LTRA
```
What would the next step be?
Refer for specialist care
Consider trials of medium dose ICS
Addition of 4th drug e.g. SR-theophylline
If these do not work, may need daily steroid tablet at lowest dose providing control
46
How would you treat mild croup?
Mostly self-limiting
Single dose of corticosteroid e.g. dexamethasone may be helpful
47
How would you manage severe croup?
Hospital admission
Steroid- dexamethasone or prednisolone before admission
In hospital- give oral/IV dexamethasone or nebulised budesonide
If this does not provide control- nebulised adrenaline
48
If someone needed oxygen therapy, in what group of patients would you give low concentration rather than high?
COPD
CF
Overdose of opioid and benzos
Lung scarring by TB
49
Theophylline is given as an injection as what drug and why?
Aminophylline, a mixture of theophylline with ethylenediamine, which is 20 times more soluble than theophylline alone
50
Beta agonists can cause deficiency in what electrolyte?
In what group of patients would this be a particular caution?
Can cause hypokalaemia if high doses used
Severe asthma- may be potentiated by concomitant treatment with theophylline, corticosteroids
51
What are the common side effects of beta agonists?
```
Arrythmias
Dizziness
Headache
Hypokalaemia (high doses)
Tremor
Palpitations
Hyperglycaemia - needs monitoring in diabetics
```
52
What is the important safety info on the use of formoterol and salmeterol in asthma?
- 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.
53
What combination is in a Fostair inhaler?
Beclometasone and formoterol
54
What is a caution in nebulised ipratropium? (what can it cause)?
How can the risk of this be reduced?
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
55
What is the MHRA advise regarding Braltus tiotropium inhalation capsules?
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
56
What combination is in a Relvar Ellipta (92/22)?
ICS LAMA
| Fluticasone and vilanterol
57
What combination is in a Seretide?
ICS LAMA
| Fluticasone and salmeterol
58
What combination is in a Symbicort Turbohaler?
ICS LAMA
| Budesonide and formoterol
59
What combination is in a Flutiform MDI?
ICS LAMA
| Fluticasone and formoterol
60
What are the LABAs licensed in asthma?
Salmeterol
Formoterol
Indacaterol
Vilanterol
61
```
If a patient is on the following:
SABA
SAMA
ICS
LABA
```
And they are prescribed a LAMA, what medicine should be stopped?
Their SAMA
62
What LAMAs are licensed in asthma?
Tiotropium Spiriva Respimat 2.5 micrograms (dose 2 puffs -5 micrograms)
63
What SABAs are licensed in asthma?
Salbutamol
| Terbutaline
64
What ICS inhalers are licensed in asthma?
Clenil (beclomethasone)
Pulmicort (budesonide)
Flixotide (fluticasone)
65
What steroid is in Clenil?
Beclomethasone
66
What steroid is in Pulmicort?
Budesonide
67
What steroid is in Flixotide?
Fluticasone
68
What ICS/LABA is licensed in asthma?
```
Relvar Ellipta
Seretide and Sirdupla
Symbicort and Duoresp
Flutiform
Fostair
```
69
What LABAs are licensed in COPD?
Indacaterol
Salmeterol
Formoterol
70
What LAMAs are licensed in COPD?
```
Glycopyyronium
Tiotropium
Aclidinium
Umeclidinium
Tiotropium
```
71
What combination is Ultibro Breezhaler?
LAMA LABA
Glycopyrronium/indacaterol
72
What combination is Anoro Ellipta?
LAMA LABA
Umeclidium/vilanterol
73
What combination is Duaklir Genuair?
LAMA LABA
Aclidinium/formoterol
74
What combination is Spiolto Respimat?
Tiotropium/Olodaterol
75
True or false:
ICS monotherapy is recommended in COPD patients
False - always prescribe in combination with LABA
Can cause pneumonia, increased ADRs and increased mortality
76
What is the difference between how to take MDI vs DPI?
MDI - slow and steady
DPI - fast and deep
77
What are the side effects of inhaled antimuscarinics (SAMA and LAMA)?
Dry mouth, headaches, nausea, arrythmias, nose bleeds
78
What is a contraindication to beta agonists?
Hint- pregnancy
Severe pre-eclampsia
79
What LABAs are licensed in COPD?
Formoterol
Salmeterol
Indacaterol
Olodaterol
80
What is the MHRA advice surrounding corticosteroids?
Rare risk of central chorioretinopathy with local and systemic administration
Patients should report any blurred vision/disturbances
81
What are the common side effects of ICS?
- Oral thrush
- Altered voice
- Cushing's syndrone
- Epistaxis
- Throat irritation
- Bronchospasm
82
What monitoring requirement is needed in children on regular ICS?
Annual height and weight
83
What is the important safety information surrounding beclometasone inhalers Qvar and Clenil?
They are not interchangeable as Qvar is more potent
| Needs to be prescribed by brand
84
Is Qvar or Clenil beclometasone inhaler more potent?
Qvar
| Has extra fine particles and is approx twice as more potent as Clenil
85
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?
1. Start with 100 mcg Qvar
| 2. Same dose as Clenil- 100 mcg
86
Are Clenil and Qvar inhalers licensed in COPD?
No- but beclometasone is licensed if in combination with formoterol (+/- glycopyrronium)
Beclometasone and formoterol - Fostair
Beclometasone and formoterol and glycopyrronium - Trimbow
87
What is the Fostair 100/6 (including nexthaler) licensed for?
COPD and asthma
88
What is the Fostair 200/6 (including nexthaler) licensed for?
Asthma only
| Not COPD
89
True or false:
| Only the higher strength Fostair (200/6) is licensed in COPD
False
It is only the 100/6 that is licensed
90
What is the beclometasone (non-extra fine particles) equivalent of 100mcg Fostair (extra fine particles)?
250 mcg
Fostair is more potent as it comtains extra fine particles
91
What combination is a Trimbow inhaler?
Beclometasone and formoterol and glycopyrronium
92
What is Trimbow licensed in?
COPD only
93
True or false:
Symbicort 100/6 is licensed in COPD
False
Those licensed in COPD:
200/6
400/12
94
Is Flutiform licensed in COPD?
No
95
What is Trelegy licensed in?
COPD only
96
What combination is Trelegy?
Fluticasone, umeclidinium and vilanterol
97
Are any inhalers just containing ICS licensed in COPD?
No
| Recommended to prescribe ICS/LABA or trio inhaler as ICS monotherapy not recommended in COPD
98
What is a rare but serious side effect of montelukast?
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.
99
What are the side effects of aminophylline?
Arrythmia (more common if IV given too rapidly)
Headache
Nausea
Seizure (more common if IV given too rapidly)
May potentiate hypokalaemia in beta 2 agonist therapy
100
With IV aminophylline, when should a blood sample be taken?
4-6 hours after starting treatment
101
What is the ideal plasma concentration for theophylline?
10-20 mg/L - above this can lead to severe side effects
102
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?
Measured 5 days after starting oral treatment and at least 3 days after any dose adjustment.
4-6 hours after
103
How does smoking interact with theophylline and how does this affect the dose needed?
Smoking can increase theophylline clearance and increased doses of theophylline are therefore required
104
What is the MHRA advice surrounding OTC chlorphenamine in children?
Children under 6 years should not be given over-the-counter cough and cold medicines containing chlorphenamine
105
What is the MHRA advice surrounding hydroxyzine (sedating antihistamine)?
QT prolongation
106
What is the MHRA advice surrounding OTC promethazine in children?
Children under 6 years should not be given over-the-counter cough and cold medicines containing promethazine
107
What drug class do you use to treat hereditary angiodema?
C1 esterase inhibitor
108
What is the 1st line mucolytic in CF?
What can be added if inadequate response?
Dornase alfa
Hypertonic sodium chloride
109
What is the MHRA advice surrounding OTC pholcodine in children?
Children under 6 years should not be given over-the-counter cough and cold medicines containing pholcodine
6-12 years- if needed, restrict to max 5 days
110
What are the symptoms of theophylline toxicity?
```
Vomiting, and vomiting up blood
Agitation
Restlessess
Dilated pupils
Sinus tachycardia
Hyperglycaemia
Convulsions
Ventricular arrhythmias
Hypokalaemia
```
111
Should theophylline be prescribed by brand?
Yes as rate of absorption can vary between brands
112
How does theophylline interact with quinolones?
Increased risk of convulsions
113
How does theophylline interact with St John's Wort?
Theophylline concentration reduced by St John's Wort (enzyme inducer)
114
How does theophylline interact with rifampicin?
Theophylline concentration reduced by rifampicin
115
How does theophylline interact with cimetidine?
Theophylline concentration increased by cimetidine
116
How does theophylline interact with fluconazole?
Theophylline concentration increased by fluconazole
117
How does theophylline interact with disulfiram?
Metabolism of theophylline is inhibited by disulfiram and therefore there is an increased risk of theophylline toxicity (hyperglycaemia, dilated pupils and haematemesis)
118
What type of inhaler is a Turbohaler?
DPI
119
What is the difference in Fostair Nexthaler and Fostair inhaler?
Nexthaler- DPI
| Fostair normal - pMDI
120
How do you calculate pack years?
(Number of cigs smoked a day/20) x number of years smoked
121
When should you refer a COPD patient for pulmonary rehabilitation?
If they are functionally disabled by COPD (usually Medical Research Council (MRC) dyspnoea scale grade 3 or above)
122
What is the purpose of pulmonary rehab for COPD patients?
- 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.
123
Long term oxygen therapy prolongs life in COPD patients. How many hours a day at least must they be on oxygen?
15 hours
124
True or false:
In COPD, if a patient is regularly using a SAMA 4 times a day, a LAMA should be offered instead
True
125
What class of drug is bambuterol?
What formulation does it come in?
LABA
| Tablet
126
What age is QVAR inhalers licensed in?
12 years
127
What is the adrenaline dose in anaphylaxis in:
i) Children < 6 years
ii) Child 6-12 years
iii) > 12 years and adults
```
IM injection (1 in 1000 solution) repeated every 5 minutes if necessary
Administer into thigh
```
i) Children < 6 years: 150 micrograms
ii) Child 6-12 years: 300 micrograms
iii) > 12 years and adults: 500 micrograms (For EpiPen brand it is 300 micrograms)
128
Patients on what medicine may not respond to adrenaline?
What could be an alternative
Beta blockers
IV salbutamol could be an alternative
129
What is the MHRA advice with adrenaline auto-injectors?
It is recommend that 2 adrenaline auto-injectors are prescribed, which patients should carry BOTH at all times.
Check expiry dates
130
What time of the day should LTRA be taken?
Evening
131
A patient requesting more than how many SABAs a month prompts a referral?
>1 a month
132
True or false:
Lung function measurements are used to guide asthma treatment of all ages
False
Not reliable in <5 years old
133
Are Ellipta inhalers DPI or MDI?
DPI
134
Can Clenil Modulite MDI be used in children?
| Is there any cut off age?
Yes - all ages
135
What type of inhaler is Clenil Modulite?
MDI
136
What type of inhaler is an Easyhaler?
DPI
137
What age is a a Beclometasone Easyhaler licensed in?
> 12 years
138
Can a Beclometasone Easyhaler be used in a 7 year old?
No
>12 years only
139
What age is a Qvar inhaler licensed in?
> 12 years
140
What type of inhaler is an Autohaler?
MDI
141
What age is Fostair licensed in?
> 18 years
142
What age is Pulmicort turbohaler licensed in?
5 years and over
143
What type of inhaler is a Turbohaler?
DPI
144
What age is Symbicort for maintenance therapy licensed in?
6 years and over
145
What age is Symbicort for maintenance AND reliever therapy licensed in?
12 years and over
146
What is the only strength Seretide Evohaler licensed in children and what is the cut off age?
25/50 licensed in children from 4 years
147
What are the 3 strengths of Seretide Evohaler?
25/50
25/125
25/250
148
What are the 3 Strengths of Seretide Accuhaler?
50/100
50/250
50/500
149
What is the only strength Seretide Accuhaler licensed in children and what is the cut off age?
50/100 licensed in children from 4 years
150
What are the 3 inhalers licensed in MART therapy and the ages they are licensed in?
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 +
151
What is the inhaler that is shaped like an egg?
Spiriva Handihaler 18 micrograms tiotropium
152
What does a whistling when a patient is using their inhaler mean?
They are breathing in too fast
153
When should you issue a steroid card to a patient on an ICS?
If on high dose ICS
