Chapter 3: Respiratory system Flashcards
DPIs are recommended in children over what age?
5 years
In 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 objects. REMIND PATIENTS:
- Remove mouthpiece cover fully, shake the device and check both outside and inside of mouthpiece are clear and undamaged before inhaling a dose.
- Store with mouthpiece cover on.
What are the different types of inhalers?
DPI
MDI
Breath actuated
How should you clean spacer devices?
Clean 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?
- b2 agonist / ipratropium bromide = acute exacerbation of asthma/COPD
- b2 agonist, corticosteroid, or ipratropium bromide on a reg basis = severe asthma or reversible airways obstruction when unable to use other inhalational devices
- An antibiotic (eg colistimethate sodium) or a mucolytic = cystic fibrosis
- Budesonide/adrenaline to 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?
Adult: SABA + Consider monitored initiation with low dose ICS
Children: Still use SABA but can start with a VERY low dose of ICS
If the pt is still symptomatic, short-lived wheezes, 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 3 times a week or more
- Waking at night symptoms at least weekly
- 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?
Initial add on therapy;
Add inhaled LABA (normally as a combination inhaler with ICS) fixed dose or MART (Maintenance + Reliever therapy)
Currently: SABA + low dose ICS + LABA
BTS asthma Adults - Pt meds:
Low dose ICS and LABA combo
SABA
If no response to the LABA, what would the next step be?
Additional controller therapy;
Consider Stopping LABA and increase dose of ICS or adding LTRA
ltra; montelukast / zafirlukast
BTS asthma Adults - Pt meds:
Low dose ICS and LABA combo
SABA
If the patient is benefitting from the LABA yet symptoms are still not being controlled, what would the next step be?
Additional controller therapy;
Continue LABA and increase ICS to medium dose
At this point can also consider trials of:
LTRA //
S-R Theophylline
LAMA
BTS asthma Adults - Patient’s regular meds:
Medium dose ICS and LABA combination
SABA & Has had a trial of LTRA
If a patient is still symptomatic, what would the next step be?
Refer to specialist care.
BTS asthma guidelines in adults:
If exercise is a specific problem in patients taking inhaled corticosteroids who are otherwise well controlled, consider adding one of the following therapies:
- leukotriene receptor antagonists
- long-acting β₂ agonists
- sodium cromoglicate or nedocromil sodium
- theophyllines.
Immediately prior to exercise, inhaled short-acting β₂ agonists are the drug of choice.
In an asthma attack, if a patient required nebulisers, is this driven by air or oxygen?
Oxygen
For asthmatic children under 5 years, what type of inhaler is recommended for bronchodilator therapy?
pMDI and spacer device, with facemask if necessary.
It contains a pressurised inactive gas that propels a dose in each ‘puff’ by pressing the top. Quick to use, small, and convenient to carry. It needs good co-ordination to press the canister and breathe in fully at the same time. Also known as “evohalers”
For asthmatic children under 5 years, what type of inhaler is recommended for corticosteroid therapy?
Pressurised metered-dose inhaler and spacer device, with a facemask if necessary
For asthmatic children between 5 and 15, what type of inhaler is recommended for corticosteroid therapy?
Pressurised metered-dose inhaler and spacer device
For asthmatic children between 5 and 15, what type(s) of inhalers is recommended for bronchodilator therapy?
Difference between pMDI, breath actuated MDI, DPI?
Consider a wider range of inhalers- not just PMDIs. What suits the patient and compliance
Pmdi; The standard MDI is the most widely used inhaler. However, common errors:
- Not shaking inhaler before using it.
- Inhaling too sharply /wrong time.
- Not holding your breath long enough after breathing in the contents.
BAI do not require you to press canister while you breathe in.
Other breath-activated inhalers are also calledDPI. These inhalers do not contain the pressurised inactive gas to propel the medicine. You don’t have to push the canister to release a dose. Instead, you trigger a dose by breathing in at the mouthpiece. Accuhalers, clickhalers, easyhalers, novolizers, turbohalers and twisthalers are all breath-activated dry powder inhalers. You need to breathe in fairly hard to get the powder into your lungs.
What is the target peak expiratory flow in asthma?
> 80%
- BTS asthma guidelines recommend that ICS should be initially taken how many times a day?
2 .What steroid is the exception to this?
- 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)
True or false:
BTS recommend that inhalers do not need to be prescribed by brand
False
They should be prescribed by brand
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?
8 weeks and then review to see if it has benefitted
If they had another exacerbation within 4 weeks of stopping, then continue
When would you consider decreasing maintenance therapy for asthma?
What is the recommended dose reduction for ICS at a time and how often?
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
Can inhaled corticosteroids be used during pregnancy for asthma?
Yes
Can oral corticosteroids be used during pregnancy for asthma?
Yes
Acute severe asthma qualifying signs/symptoms?
What is 1st line for acute asthma in adults?
Acute severe asthma qualifies for any of:
• PEF 33–50% best or predicted
• respiratory rate ≥25/min
• heart rate ≥110/min
• inability to complete sentences in one breath
■ Supplementary oxygen to all hypoxaemic pts. Maintain SpO2level 94–98%. Do not delay if pulse oximetry is unavailable.
■ 1st line: high-dose inhaled SABA (salbutamol/terbutaline) ASAP. If response is poor, consider continuous nebulisation. IV b2agonists are reserved for whom inhaled therapy cannot be used reliably.
■ In all cases of acute asthma, prescribe adequate dose of oralprednisolone. Continue ICS during oral corticosteroid treatment. Parenteralhydrocortisoneor IMmethylprednisoloneare alternatives if unable to take oralprednisolone.
In what situation would you use IV beta 2 agonists for acute asthma in adults?
IV beta2agonists are reserved for those patients in whom inhaled therapy cannot be used reliably.
In severe acute adult asthma, if the patient has poor response to nebulised SABA, what can be added?
Nebulised ipratropium
What kind of drug is ipratropium?
SAMA
What kind of drug is tiotropium?
LAMA
Are brands of ICS interchangeable?
No- all contain different doses of different steroids
Is LABA monotherapy recommended in asthma?
No
Should always have an ICS or combination inhaler with ICS
Associated with ADRs and death
What type of inhaler is an accuhaler?
DPI
What type of inhaler is an evohaler?
MDI
What is a disadvantage of a DPI?
Breath actuated, need to have respiratory effort for it
If not, MDI is more appropriate
What is the only LAMA licensed for asthma?
Tiotropium
Which tiotropium inhaler is licensed in asthma?
Spiriva Respimat 2.5 mcg (2p OD)
The following are only licensed in COPD:
- Braltus 10 mcg capsules (Zonda)
- Spiriva 18 mcg capsules (Handihaler)
What is the only Seretide licensed in COPD?
Seretide 500 Accuhaler
Fluticasone/salmeterol
The lower dose Seretide accuhalers and the evohalers are not licensed
(But all Seretides are licensed for asthma)
In children of all ages, what do you give for acute asthma?
Inhaled SABA
Once daily dose of oral pred, usually for 3 days or until recovery
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
BTS guidelines:
In paediatric asthmatic patients, if they are on a SABA and a very low dose ICS, what would the next step be?
- SABA alone
- Monitored initiation of very low to low dose ICS
- Regular preventer: SABA + very low dose ICS
● or <5yrs LTRA - Initial Add on therapy; SABA +
● increase to low dose ICS or
● 5 years and above: Add inhaled LABA or LTRA
If no response to LABA consider Stopping LABA
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?
- SABA alone
- Monitored initiation of very low to low dose ICS
- Regular preventer: SABA + very low dose ICS
● or <5yrs LTRA - Initial Add on therapy; SABA +
● increase to low dose ICS or
● 5 years and above: Add inhaled LABA or LTRA
If no response to LABA consider Stopping LABA, increase to low dose ICS
- Additional controller therapies
● increase ICS to low dose or
● 5 yrs or above Add LTRA/LABA
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?
- SABA alone
- Monitored initiation of very low to low dose ICS
- Regular preventer: SABA + very low dose ICS
● or <5yrs LTRA - Initial Add on therapy; SABA +
● increase to low dose ICS or
● 5 years and above: Add inhaled LABA or LTRA
If no response to LABA consider Stopping LABA - Additional controller therapies
● increase ICS to low dose or
● 5 yrs or above Add LTRA/LABA - Specialist referral
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
How would you treat mild croup?
Mostly self-limiting
Single dose of corticosteroid e.g. dexamethasone may be helpful
How would you manage severe croup?
Hospital admission
Steroid- dexa or pred b4 admission
Hospital- give oral/IV dexa or nebulised budesonide
- If this does not provide control- nebulised adrenaline
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
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
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
What are the common side effects of beta agonists?
Arrythmias Dizziness Headache Hypokalaemia (high doses) Tremor Palpitations Hyperglycaemia - needs monitoring in diabetics
What is the important safety info on the use of formoterol and salmeterol in asthma?
- added only if standard-dose ICS failed;
- no initiation in rapidly deteriorating asthma;
- intro at low dose and properly monitor before dose increase;
- be discontinued in the absence of benefit;
not be used for the relief of exercise-induced asthma symptoms unless regular ICS are also used; - be reviewed as clinically appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved.
What combination is in a Fostair inhaler?
Beclometasone and formoterol
What is a caution in nebulised ipratropium? (what can it cause)?
How can the risk of this be reduced?
Acute angle closed glaucoma, esp in combo with nebulised salbutamol.
Need to protect eyes from neb. drug or powder. If nebulised iptratropium is needed, they need a very tight fitting nebs mask
ALSO cautioned in enlarged prostate and bladder outflow obstruction
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
What combination is in a Relvar Ellipta (92/22)?
ICS LAMA
Fluticasone and vilanterol
What combination is in a Seretide?
ICS LAMA
Fluticasone and salmeterol
Seretide S- salmeterol TID - TIC - FLUTICASONE
What combination is in a Symbicort Turbohaler?
ICS LAMA
Budesonide and formoterol
Sym - y ‘ f ‘ formoterol
Bi - budesonide
What combination is in a Flutiform MDI?
ICS LAMA
Fluticasone and formoterol
What are the LABAs licensed in asthma?
Salmeterol
Formoterol
Indacaterol
Vilanterol
If a patient is on the following: SABA SAMA ICS LABA
And they are prescribed a LAMA, what medicine should be stopped?
Their SAMA