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A - BNF CHAPTER 3 - RESP > Chapter 3: Respiratory System > Flashcards

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

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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.

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3
Q

What are the different types of inhalers?

A

DPI
MDI
Breath actuated

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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.

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5
Q

How often should spacers be replaced?

A

Every 6-12 months

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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.
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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.

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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

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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
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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)

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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

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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

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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

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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

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15
Q

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

A

Oxygen

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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

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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

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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

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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

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20
Q

What is the target peak expiratory flow in asthma?

A

> 80%

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21
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)

  1. Ciclesonide should be taken only once daily initially (only twice daily in severe asthma)
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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

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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

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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

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25
Q

Can inhaled corticosteroids be used during pregnancy for asthma?

A

Yes

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26
Q

Can oral corticosteroids be used during pregnancy for asthma?

A

Yes

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27
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 recommended

Life-threatening - oxygen driver nebuliser recommended

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28
Q

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

A

If inhaled therapy cannot be used reliably

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29
Q

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

A

Nebulised ipratropium

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30
Q

What kind of drug is ipratropium?

A

SAMA

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31
Q

What kind of drug is tiotropium?

A

LAMA

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32
Q

Are brands of ICS interchangeable?

A

No- all contain different doses of different steroids

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33
Q

Is LABA monotherapy recommended in asthma?

A

No
Should always have an ICS or combination inhaler with ICS

Associated with ADRs and death

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34
Q

What type of inhaler is an accuhaler?

A

DPI

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35
Q

What type of inhaler is an evohaler?

A

MDI

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36
Q

What is a disadvantage of a DPI?

A

Breath actuated, need to have respiratory effort for it

If not, MDI is more appropriate

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37
Q

What is the only LAMA licensed for asthma?

A

Tiotropium

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38
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)

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39
Q

What is the only Seretide licensed in COPD?

A

Seretide 500 Accuhaler

The lower dose Seretide accuhalers and the evohalers are not licensed

(But all Seretides are licensed for asthma)

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40
Q

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

A

Inhaled SABA

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

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41
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

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42
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 LTRA

5 years and above: Add inhaled LABA

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43
Q

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?

A

Stop LABA and increase ICS to a low dose

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44
Q

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?

A

Continue LABA but increase ICS to a low dose

Also consider trial of other therapy e.g. LTRA if not on already

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45
Q

BTS guidelines for paediatric asthma

If a patient is on: 
SABA 
Low dose ICS 
LABA 
LTRA

What would the next step be?

A

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

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46
Q

How would you treat mild croup?

A

Mostly self-limiting

Single dose of corticosteroid e.g. dexamethasone may be helpful

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47
Q

How would you manage severe croup?

A

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

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48
Q

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

A

COPD
CF
Overdose of opioid and benzos
Lung scarring by TB

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49
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

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50
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 used

Severe asthma- may be potentiated by concomitant treatment with theophylline, corticosteroids

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51
Q

What are the common side effects of beta agonists?

A 
Arrythmias
Dizziness 
Headache 
Hypokalaemia (high doses) 
Tremor 
Palpitations 
Hyperglycaemia - needs monitoring in diabetics
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52
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.
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53
Q

What combination is in a Fostair inhaler?

A

Beclometasone and formoterol

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54
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

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55
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

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56
Q

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

A

ICS LAMA

Fluticasone and vilanterol

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57
Q

What combination is in a Seretide?

A

ICS LAMA

Fluticasone and salmeterol

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58
Q

What combination is in a Symbicort Turbohaler?

A

ICS LAMA

Budesonide and formoterol

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59
Q

What combination is in a Flutiform MDI?

A

ICS LAMA

Fluticasone and formoterol

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60
Q

What are the LABAs licensed in asthma?

A

Salmeterol
Formoterol
Indacaterol
Vilanterol

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61
Q 
If a patient is on the following:
SABA 
SAMA 
ICS 
LABA

And they are prescribed a LAMA, what medicine should be stopped?

A

Their SAMA

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62
Q

What LAMAs are licensed in asthma?

A

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

63
Q

What SABAs are licensed in asthma?

A

Salbutamol

Terbutaline

64
Q

What ICS inhalers are licensed in asthma?

A

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

65
Q

What steroid is in Clenil?

A

Beclomethasone

66
Q

What steroid is in Pulmicort?

A

Budesonide

67
Q

What steroid is in Flixotide?

A

Fluticasone

68
Q

What ICS/LABA is licensed in asthma?

A 
Relvar Ellipta
Seretide and Sirdupla 
Symbicort and Duoresp 
Flutiform 
Fostair
69
Q

What LABAs are licensed in COPD?

A

Indacaterol
Salmeterol
Formoterol

70
Q

What LAMAs are licensed in COPD?

A 
Glycopyyronium
Tiotropium 
Aclidinium 
Umeclidinium 
Tiotropium
71
Q

What combination is Ultibro Breezhaler?

A

LAMA LABA

Glycopyrronium/indacaterol

72
Q

What combination is Anoro Ellipta?

A

LAMA LABA

Umeclidium/vilanterol

73
Q

What combination is Duaklir Genuair?

A

LAMA LABA

Aclidinium/formoterol

74
Q

What combination is Spiolto Respimat?

A

Tiotropium/Olodaterol

75
Q

True or false:

ICS monotherapy is recommended in COPD patients

A

False - always prescribe in combination with LABA

Can cause pneumonia, increased ADRs and increased mortality

76
Q

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

A

MDI - slow and steady

DPI - fast and deep

77
Q

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

A

Dry mouth, headaches, nausea, arrythmias, nose bleeds

78
Q

What is a contraindication to beta agonists?Hint- pregnancy

A

Severe pre-eclampsia

79
Q

What LABAs are licensed in COPD?

A 
Formoterol
Salmeterol 
Indacaterol 
Olodaterol
--
80
Q

What is the MHRA advice surrounding corticosteroids?

A

Rare risk of central chorioretinopathy with local and systemic administration

Patients should report any blurred vision/disturbances

81
Q

What are the common side effects of ICS?

A
  • Oral thrush
  • Altered voice
  • Cushing’s syndrone
  • Epistaxis
  • Throat irritation
  • Bronchospasm
82
Q

What monitoring requirement is needed in children on regular ICS?

A

Annual height and weight

83
Q

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

A

They are not interchangeable as Qvar is more potent

Needs to be prescribed by brand

84
Q

Is Qvar or Clenil beclometasone inhaler more potent?

A

Qvar

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

85
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 Qvar

2. Same dose as Clenil- 100 mcg

86
Q

Are Clenil and Qvar inhalers licensed in COPD?

A

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

Beclometasone and formoterol - Fostair

87
Q

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

A

COPD and asthma

88
Q

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

A

Asthma only

Not COPD

89
Q

True or false:

Only the higher strength Fostair (200/6) is licensed in COPD

A

False

It is only the 100/6 that is licensed

90
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

91
Q

What combination is a Trimbow inhaler?

A

Beclometasone and formoterol and glycopyrronium

92
Q

What is Trimbow licensed in?

A

COPD only

93
Q

True or false:

Symbicort 100/6 is licensed in COPD

A

False

Those licensed in COPD:
200/6
400/12

94
Q

Is Flutiform licensed in COPD?

A

No

95
Q

What is Trelegy licensed in?

A

COPD only

96
Q

What combination is Trelegy?

A

Fluticasone, umeclidinium and vilanterol

97
Q

Are any inhalers just containing ICS licensed in COPD?

A

No

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

98
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

99
Q

What are the side effects of aminophylline?

A

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
Q

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

A

4-6 hours after starting treatment

101
Q

What is the ideal plasma concentration for theophylline?

A

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

102
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

103
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

104
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

105
Q

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

A

QT prolongation

106
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

107
Q

What drug class do you use to treat hereditary angiodema?

A

C1 esterase inhibitor

108
Q

What is the 1st line mucolytic in CF?

What can be added if inadequate response?

A

Dornase alfa

Hypertonic sodium chloride

109
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 pholcodine

6-12 years- if needed, restrict to max 5 days

110
Q

What are the symptoms of theophylline toxicity?

A 
Vomiting, and vomiting up blood 
Agitation 
Restlessess 
Dilated pupils 
Sinus tachycardia 
Hyperglycaemia 
Convulsions 
Ventricular arrhythmias 
Hypokalaemia
111
Q

Should theophylline be prescribed by brand?

A

Yes as rate of absorption can vary between brands

112
Q

How does theophylline interact with quinolones?

A

Increased risk of convulsions

113
Q

How does theophylline interact with St John’s Wort?

A

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

114
Q

How does theophylline interact with rifampicin?

A

Theophylline concentration reduced by rifampicin

115
Q

How does theophylline interact with cimetidine?

A

Theophylline concentration increased by cimetidine

116
Q

How does theophylline interact with fluconazole?

A

Theophylline concentration increased by fluconazole

117
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)

118
Q

What type of inhaler is a Turbohaler?

A

DPI

119
Q

What is the difference in Fostair Nexthaler and Fostair inhaler?

A

Nexthaler- DPI

Fostair normal - pMDI

120
Q

How do you calculate pack years?

A

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

121
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)

122
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.
123
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

124
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

125
Q

What class of drug is bambuterol?

What formulation does it come in?

A

LABA

Tablet

126
Q

What age is QVAR inhalers licensed in?

A

12 years

127
Q

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
A

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
Q

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

A

Beta blockers

IV salbutamol could be an alternative

129
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

130
Q

What time of the day should LTRA be taken?

A

Evening

131
Q

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

A

> 1 a month

132
Q

True or false:

Lung function measurements are used to guide asthma treatment of all ages

A

False

Not reliable in <5 years old

133
Q

Are Ellipta inhalers DPI or MDI?

A

DPI

134
Q

Can Clenil Modulite MDI be used in children?

Is there any cut off age?

A

Yes - all ages

135
Q

What type of inhaler is Clenil Modulite?

A

MDI

136
Q

What type of inhaler is an Easyhaler?

A

DPI

137
Q

What age is a a Beclometasone Easyhaler licensed in?

A

> 12 years

138
Q

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

A

No

> 12 years only

139
Q

What age is a Qvar inhaler licensed in?

A

> 12 years

140
Q

What type of inhaler is an Autohaler?

A

MDI

141
Q

What age is Fostair licensed in?

A

> 18 years

142
Q

What age is Pulmicort turbohaler licensed in?

A

5 years and over

143
Q

What type of inhaler is a Turbohaler?

A

DPI

144
Q

What age is Symbicort for maintenance therapy licensed in?

A

6 years and over

145
Q

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

A

12 years and over

146
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

147
Q

What are the 3 strengths of Seretide Evohaler?

A

25/50
25/125
25/250

148
Q

What are the 3 Strengths of Seretide Accuhaler?

A

50/100
50/250
50/500

149
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

150
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 +

151
Q

What is the inhaler that is shaped like an egg?

A

Spiriva Handihaler 18 micrograms tiotropium

152
Q

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

A

They are breathing in too fast

153
Q

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

A

If on high dose ICS

A - BNF CHAPTER 3 - RESP (7 decks)

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