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Pre-reg > Chapter 3- Respiratory System > Flashcards

Chapter 3- Respiratory System Flashcards

1
Q

Why’s inhalation method preferred for drug delivery to the respiratory system

A

Drug delivered directly to the airways
The dose required is smaller
Side effects reduced

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2
Q

What is complete control of asthma defined as

A

No daytime symptoms

No night time awakening due to asthma

No asthma attacks

No need for rescue medication

No limitation to activity

Normal lung function

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3
Q

Treatment ladder recommendations for asthma

A

Intermittent reliever therapy:
Start an inhaled short acting beta2 agonist (salbutamol) to be used PRN for infrequent wheezing

Regular preventer therapy:
A low dose inhaled corticosteroids should be started as maintenance therapy in patients using the SABA regularly, waking up due to asthma or had an attack in the last 2 years

Initial add on therapy:
If not controlled on low ICS a LABA

Additional add on therapy:
If LABA not effective stop. If effective but not enough increase ICS to medium dose or consider a third agent (LTRA, MR theophylline)

ConsiderSwitch to MART (maintenance and reliever therapy) a combination of an ICS a fast acting LABA and a low dose ICS as therapy

If MART not effective use 4 agents: continue on high dose ICS, LABA, and either leukotriene receptor antagonist, long acting muscarinic receptor antagonist or MR theophylline or oral b2 agonist tablet (bambuterol)

Step 5 is oral pred while continuing high dose ICS

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4
Q

Which asthmatic medications should be held in pregnancy

A

None

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5
Q

What peak flow value indicated normal lung function

A

> 80% predicted or best

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6
Q

When can you start to consider decreasing asthmatics treatment

A

When their asthma has been controlled with their current therapy for Atleast 3 months

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7
Q

What’s should children be Monitored for when starting a steroid for asthma

A 
Growth failure 
Reduces bone mineral density 
Adrenal suppression 
Eyes for cataracts 
Weight and height for growth
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8
Q

Management of a severe asthma attack

A

High flow oxygen to maintain levels between 94-98%

Beta2 agonist administered by an oxygen driven nebuliser

Oral prednisolone once daily for Atleast 5 days or until recovery

Can add the following if no improvement:

  • nebulised ipratropium
  • IV magnesium sulfate
  • IV aminophylline (caution with patients on theophylline)
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9
Q

What’s the treatment ladder for COPD

A

Breathlessness and exercise limitation:
- short acting b2 agonist or short acting muscarinic antagonist prn (iprtropium)

Exacerbation or persistent:
FEV1> 50%
-LABA
-LAMA (discontinue SAMA) tiotropium

FEV1< 50%

  • LABA + ICS
  • LAMA (discontinue SAMA)

Persistent exacerbation:
- LAMA + LABA + ICS

Last resort:
Aminophylline or theophylline with long term oxygen therapy

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10
Q

What can reduce mortality risk of COPD

A

Not smoking if a smoker
Weight loss if overweight
Vaccinating against influenza

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11
Q

When are mucolytic drugs useful in COPD

A

If it is associated with a productive cough

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12
Q

How are COPD flare ups treated

A

Corticosteroids or antibacterial if an infection is suspected

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13
Q

What are the most effective SABA and why

A

Salbutamol and terbutaline

As they’re selective unlike ephedrine

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14
Q

What are SABA used for

A

Immediate relief of asthma symptoms

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15
Q

What’s a risk of using SABA and when is the risk heightened

A

Hypokalaemia

Heightened when used with theophylline, corticosteroids and diuretic
Also worse when patient is hypoxia

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16
Q

How long does SABA effects last

A

3-5 hours

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17
Q

Give examples of LABA and its use

A

Salmeterol and formoterol

Role in long term control of chronic asthma in patients who regularly use an ICS
(Salmeterol should not be used for acute relief of asthma attack as onset is too slow)

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18
Q

How long does LABA effects last

A

Up to 12 hours

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19
Q

Side effects of b2 agonists (bronchodilator)

A 
Tremor 
Headache, muscle cramps, palpitations 
Bronchospasm 
Tachycardia, arrhythmia 
MI
Sleep disturbances
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20
Q

What’s an example of a SAMA

A

Ipratropium

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21
Q

Examples of LAMA

A

Tiotropium
Glycopyrronium
Aclidinium

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22
Q

How long does SAMA effects last

A

3-6 hours

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23
Q

Caution with the use of SAMA and LAMA

A

Prostatic hyperplasia
Bladder outflow obstruction
Angle- closure glaucoma (reported with nebulised ipratropium particularly when given with nebulised salbutamol)

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24
Q

Side effects of Antimuscarinic bronchodilators

A

Dry mouth
Constipation, cough
Headache, dizziness

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25
Q

What’s the CHM advice for the use of LABA

A

To be added if control with regular ICS has failed

Not to be initiated in deteriorating asthma

Be introduced at a low dose and the effect properly monitored before considering dose increase

Be discontinued if absence of benefit

Not to be used PRN for exercise unless ICS is also used

Review to step down as soon as appropriate

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26
Q

How are corticosteroids effective in asthma

A

They reduce airway inflammation and hence reduce oedema and secretion of mucus into the airway

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27
Q

Examples of inhaled corticosteroids

A

Beclometasone
Budesonide
Fluticasone
Momentasone

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28
Q

How are inhaled corticosteroids effective in COPD

A

May reduce exacerbation when given in combination with an inhaled LABA

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29
Q

Common side effects of ICS

A

Oral thrush
Altered taste
Voice alterations
LRTI Pneumatic in patients with COPD

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30
Q

Why should ICS be prescribed by Brand

A

They’re not interchangeable
QVAR is twice as potent as Clenil
Forst air is a combination and is also more potent

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31
Q

What’s some unlicensed uses of beclometasone

A

Easyhaler not liveeee for children under 18 year

QVAR, clenil 200,250 not licensed for children under 12

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32
Q

How can Inhaled corticosteroids distinguish between asthma and COPD

A

If consistent use and improvement over 3-4 weeks, suggests asthma

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33
Q

How can you manage oral thrush from the use of ICS

A

Use spacer
Rinse mouth after
antifungal can be used to treat thrush without stopping treatment

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34
Q

How does montelukast work

A

It blocks the effect of leukotrienes (inflammatory mediators) in the airways

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35
Q

Examples of Xanthines

A

Aminophylline and theophylline

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36
Q

How are Xanthines used

A

Used as Antimuscarinic bronchodilator in asthma and stable COPD (not effective in exacerbation of COPD)

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37
Q

When might theophylline have additive effects

A

When used with beta2 agonists

Can especially exacerbate hypokalaemia

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38
Q

Where is theophylline metabolised and what increased its plasma concentration

A

Metabolised in the liver.

Heart failure 
Hepatic impairment 
Viral infections 
Elderly 
Drugs that inhibit it’s metabolism (diltiazem, erythromycin, ciprofloxacin)
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39
Q

What decreased theophyllines plasma concentration

A

Smokers
Alcohol consumption
Drugs that induce its metabolism (carbamazepine, primidone, phenytoin and phenobarbital)

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40
Q

Theophylline therapeutic range

A

10-20mg/L

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41
Q

How is aminophylline administered

A

By very slow IV injections over Atleast 20 minutes as it’s too irritant for IM

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42
Q

Warning signs for theophylline

A

Toxicity

Uncontrolled asthma

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43
Q

What needs to be monitored with theophylline

A

Serum potassium

Plasma theophylline concentration

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44
Q

What’s important about prescribing theophylline and aminophylline

A

Maintaining the same brand

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45
Q

What’s croup and how is it treated

A

Infection in the upper airway that blocks breathing and causes barking cough

Usually self limiting but can give single dose corticosteroids (dexamethasone)

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46
Q

What’s used in asthma management but ineffective in COPD

A

Leukotriene antagonist

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47
Q

What do anti histamines have a role in

A 
Nasal allergies
Runny nose (rhinorrhoea)
Rashes
Insect bites
Drug allergies
Nausea and vomiting 
Occasional insomnia
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48
Q

How are the new generations antihistamine different to the older generation and why

A

Newer cause less sedation and psychomotor impairment because they penetrate the BBB only to a slight extent

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49
Q

What’s the first line treatment and route for anaphylaxis reaction

A

Adrenaline 500micrograms

Via intramuscular route

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50
Q

Same the sedating antihistamines (older gen)

A

Promethazine
Alimemazine
Chlorphenamine
Hydroxyzine

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51
Q

Name the newer non-sedating antihistamines

A 
Cetirizine
Fexofenadine 
Loratidine
Acrivastine 
Desloratidine 
Levocetitizine
Mizolastine
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52
Q

What’s the rare side effect of all antihistamine

A 
Hypotension 
Palpitation 
Arrhythmia 
EPSA
Dizziness 
Confusion
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53
Q

What do sedating antihistamines have a significant effect on and when should it be cautioned

A

Antimuscarinic activity

Cautioned in prostatic hyperteophy, urinary retention and susceptibility to angle-closure glaucoma

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54
Q

What symptoms do antihistamines not help with

A

Nasal congestion

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55
Q

Which antihistamine is taken upto 4 times a day

A

Chlorphenamine

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56
Q

When should sedating antihistamines be avoided and why

A

Liver disease

Risk of coma

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57
Q

What should be counselled to be avoided in excess when taking antihistamine

A

Alcohol

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58
Q

What should be given in an anaphylactic/ angioedema reaction

A 
Adrenaline/ epinephrine (5minute intervals)
Oxygen 
Antihistamine 
Corticosteroids 
IV fluids
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59
Q

From what age is chlorphenamine and promethazine licensed to be sold OTC

A

6 and above

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60
Q

What risk is hydroxyzine been associated with and what did the meds review conclude to minimise the risk

A

Small risk of QT interval prolongation and torsade de pointes

To minimise the side effects the restrictions are:

  • contraindicated in patients with or at risk of QT prolongation
  • avoid use in elderly
  • in adults max daily dose is 100mg, in elderly max daily dose 50mg (if use can’t be avoided)
  • in children upto a body weight of 40kg max daily dose is 2mg/kg
  • prescribe at lowest affective dose for shortest period of time
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61
Q

Name some mucolytics and how are they used in COPD

A

Carboceisteine
Acetylcysteine

Reduce sputum viscosity and can reduce exacerbation in some COPD patients and people with chronic productive cough
(Therapy should be stopped after 4 weeks with no benefit)

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62
Q

What age is aromatic decongestant not advised, what can be carried out instead?

A

Under 3 months

Sodium chloride nasal drops or sunction aspiration

63
Q

Examples of demulcent preparations and their effect

A

Glycerol
Simple linctus

Soothing

64
Q

Examples of expectorants and effects

A

Guaifenesin
Ipecacuanha

Expel bronchial secretions

65
Q

OTC cough preparations should not be sold for children under 6 if they contain what?

A

Antihistamines
Cough suppressant (eg: pholocodiene)
Expectorants (eg: Guaifenesin)
Decongestants (eg: pseudoephedrine)

66
Q

What’s the duration you can sell OTC cough preparations to 6-12 years old

A

5 days or less

67
Q

When should decongestants be cautioned and avoided

A

Cautioned in patients with diabetes, hypertension, hyperthyroidism

Avoided in patients taking MAOIs

68
Q

What’s used as a cough suppressant (antitussive)

A

Codeine
Pholocodine
Dextromethorphan

69
Q

What PEF would you expect to see for a patient having a severe asthma attack

A

33%-50%

70
Q

How is asthma diagnosed

A

Presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough)

And variable airflow obstruction

71
Q

How should patients ICS be decreased

A

25-50% every 3 months to the lowest effective dose

72
Q

Symptoms of moderate acute asthma attack

A

PEF 50-75

Increasing symptoms

73
Q

Symptoms of acute severe asthma attack

A

PEF 33-50
RR >25/min
HR >110/min
Can’t complete sentences in one breath

74
Q

What does Fostair contain

A

Beclometasone and formoterol

75
Q

What does spiromax and symbicort contain

A

Budesonide and formoterol

76
Q

What does seretide contain

A

Fluticasone and salmeterol

77
Q

Why should salmeterol not be used for the acute relief or prevention of exercise induced asthma

A

Long onset of action

78
Q

Which ICS can be taken once daily

A

Ciclesonide

Momentasone

79
Q

What is aminophylline a mixture of

A

Theophylline and ethylenediamine

80
Q

When should theophylline be sampled after dose

A

4-6 hours

81
Q

What’s the oxygen therapy for severe COPD with hypoxaemia

A

15 hours a day or more
88-92% O2 saturation
Must carry O2 alert card and use a 24% or 28% Venturi mask of history of hypercapnia respiratory failure

82
Q

How should self administered adrenaline be used

A

2 carried at all times
Administer mid point of outer thigh
Second injection 5-15 minutes after first injection
Call ambulance if symptoms don’t improve
Lie down and raise legs (sit up if difficulty breathing)

83
Q

Adrenaline autojector dose

A

Adult= 300-500mcg

Child 15-30kg= 150mcg

84
Q

Contraindications for mucolytics

A

Active peptic ulceration as it disrupts gastric mucosa

85
Q

What electrolyte disturbance can occur with the coadministration of salbutamol and theophylline

A

Hypokalaemia

86
Q

When do you check theophylline doses when starting and after dose changes

A

5 days after starting

3 days after dose change

87
Q

Signs of theophylline toxicity

A

Vomiting and GI effects
Tachycardia
Arrhythmia, convulsion and hypokalaemia

88
Q

What medication should daktarin gel (miconazole) not be taking with

A

Warfarin

89
Q

How can you manage mild bronchospasm from ICS

A

Use SABA beforehand

Transfer pMDI to dry powder inhaler

90
Q

What dose of prednisone would you expect to see for the treatment of an acute asthma attack in an adult

A

40-50mg for 5 days

Child under 12: upto 3 days

91
Q

Why electrolyte disturbance is caused from SABA and LABA

A

Hypokalaemia

92
Q

What electrolyte disturbance can potentially occur with co administration of theophylline and salbutamol

A

Hypokalaemia

93
Q

What PEF would be expected for an adult who is defined as having a severe asthma attack

A

33-50%

94
Q

Theophylline side effects

A 
Arrhythmia 
CNS stimulation 
Convulsions 
Diarrhoea 
GI irritation 
Headache 
Insomnia 
Palpitation 
Tachycardia 
Vomiting
95
Q

How do you inhale steroid inhalers?

A

Quick and deep

96
Q

What PEF would you expect to find for an adult who is defined as having moderate asthma attack

A

50-75%

97
Q

Who should be given oral prednisolone with asthma

A

Anyone who’s had an asthma attack

Minimum 5 days

98
Q

There’s an increased risk of of hypokalaemia when theophylline is taken with which drugs

A

LOOP diuretics
Thiazide diuretics
Corticosteroids
B2 agonist

99
Q

How should ICS initially be used when starting

A

Twice daily (except ciclesonide)

100
Q

What condition should beta 2 agonist be cautioned with

A

Diabetes

101
Q

What inhalvers have extra fine particles

A

QVAR

Fostair

102
Q

When should a large volume spacer be used

A

High dose ICS

Patients under 15

103
Q

Why might smokers need a higher ICS dose

A

Current and ex smokers reduces effectiveness of ICS so might need a higher dose

104
Q

What’s the dose for SAMA

A

TDS

105
Q

What’s the dose of LAMA

A

OD (except Eklira BD)

106
Q

What steroid dose would you give for a COPD exacerbation

A

30mg OD for 7-14 days

107
Q

What’s the most sedating old antihistamine

A

Promethazine

Alimemazine

108
Q

Which antihistamine causes QT prolongation

A

Hydroxyzine

109
Q

What’s an nsaid antihistamine

A

Ketotifen

110
Q

How do decongestants work and when should they be avoided

A

Narrow blood vessels to reduce inflammation

Avoided in: 
Heart problems 
High blood pressure 
Overactive thyroid 
Diabetes 
Pregnant women
111
Q

How long can nasal decongestant be used and why

A

No longer than 7 days

Causes rebound congestion

112
Q

What time should decongestants not be taken and why

A

Night

They have a stimulant effect

113
Q

Why’s the sale of pseudoephedrine monitored

A

Aj be used to make methylamphetamine

114
Q

What meds should be used for productive cough and which for non productive cough

A

Productive: expectorants (guaifenesin)

Non productive: suppressant (codeine, pholocodeine, dextromethorphan)

115
Q

What antihistamine can be used to reduce a cough

A

Diphenhydramine

116
Q

What’s the sale limit for products containing pseudoephedrine or epherdine to a person at one time in one transaction

A

720mg of pseudoephedrine

180mg of ephedrine

117
Q

What inhalants can be used OTC to help clear catarrh

A

Menthol, pine oil eucalyptus

118
Q

When to refer colds and flus

A

Earache not settling with analgesic
Facial pain or frontal headache
Very young
Very old
Heart or lung disease
With persistent fever and productive cough
Chest pain
Delirium
At risk patients (high BP, diabetics, asthmatics)
No improvement after 14 days of self medication

119
Q

When to refer coughs

A 
Lasting > 2 weeks 
Colour sputum 
Chest pain 
Shortness of breath 
Wheezing 
Whooping cough or croup 
Failed medication 
Recurrent night time coughing
120
Q

Sore throat OTC treatment options

A

Simple analgesic

Flubiprofen- NSAID lozenges
Difflam- NSAID

Tyrothricin- antibiotic lozenges

Local anaesthetic- dumbing effect

Demulcent pastilles- lubricating effect

121
Q

When to refer for sore throats in a community setting

A 
Sore throat lasting more than a week 
Recurrent blunts of infection 
Hoarseness for more that 2 weeks 
Difficulty swallowing 
Failed medication 
Carbimazole patients
122
Q

What age is steroid nasal sprays licensed to be sold otc

A

18+

123
Q

OTC products available for topical decongestant

A

Xylometazoline

Oxymetazoline

124
Q

What’s the first line OTC antihistamine for hayfever

A

Loratidine as it’s least likely to cause sedation

125
Q

What age are nasal decongestant like xylometazoline and oxymetazoline licensed to be sold OTC

A

12

126
Q

Why should decongestant be avoided in a few conditions

A

They increase blood sugar levels, heart rate and muscle tremor

127
Q

Whats the best assessment for asthma control

A

Symptoms

128
Q

What age can peak flow meters be used from

A

5

129
Q

How should aminophylline be administered for severe acute asthma

A

5mg/ kg

Over 20 minutes

130
Q

What does drying a spacer with a cloth do

A

It increases the chances of electrostatic charges

131
Q

What are alternatives for SABA

A

SAMA- ipratropium

If 12+ years- theophylline or oral b2 agonist (bambuterol)

132
Q

With asthma treatment, what symptoms will prompt you to step up

A

Symptoms 3 times a week

Night time symptoms once a week

Asthma attack requiring systemic steroids in last 2 years

Refer if using >1 inhaler a month, not wel controlled

133
Q

When should you advice the patient to see the gp if a Saba fails to provide relief for a certain length of time

A

< 3 hours

134
Q

What brands contain formoterol

A

Fostair
Duoresp
Spiromax
Symbicort (18+)

135
Q

What’s the order of potency in beclometasone inhalers

A

Fostair (most)

Qvar

Clenil

Other CFC containing beclometasone (least)

136
Q

What should you do if paradoxical bronchospasm is experienced from ICS

A

Stop and give alternative

137
Q

What group of patients might need a higher dose of ICS and why

A

Current and previous smokers

As it reduced effectiveness of ICS

138
Q

What are used of LRTI

A

Chronic asthma

Symptomatic relief of hay fever in asthma

139
Q

Side effect of LRTI

A

Churg strauss syndrome- occurs on withdrawal of oral corticosteroids

Zafirlukast (liver toxicity)

140
Q

When what drugs are given with theophylline it increases risk of hypokalaemia

A

Loop or Thiazide diuretics
Corticosteroids
B2 agonist

141
Q

What does theophylline interact with to increase risk of seizures

A 
Ciprofloxacin 
Quinolone (lowers seizure threshold)- Pd interaction
142
Q

Example of enzyme inhibitor that increase theophylline levels

A

Quinolones - pk interaction

143
Q

What medication causes an increase plasma concentration of theophylline and risk of toxicity

A 
Verapamil/ calcium channel blocker 
Cimetidine 
Phenytoin 
Fluconazole 
Macrolides

(All enzyme inhibitors)

144
Q

What medication causes a decrease in plasma concentration of theophylline and is subtherapeutic

A

St. John’s wort

Rifampicin

145
Q

Which LAMA can be used in asthma with 1 or more severe exacerbation in the last year

A

Tiotropium (spiriva respimat)

146
Q

Uses of antihistamines

A

Allergies (nasal and skin)
Nausea and vomiting
Insomnia
Emergency anaphylaxis and angioedema

147
Q

What is allergen immunotherapy and who should it be avoided in

A

When the patient is exposed to the exact thing they are allergic to to make the desensitised

Avoided in
Asthmatic
Pregnant women
Children under 5
People on BB
people on ACEi
148
Q

What’s the safety concerns regarding desensitising vaccines

A

Hypersensitivity reactions

Life threatening bronchospasm and anaphylaxis

Must be monitored for 1 hour and cpr readily available

149
Q

How does adrenaline help on an anaphylaxis reaction

A

Dilates the lungs to open airways

Constricts vessels to increase BP

150
Q

Should an ambulance be called if an adrenaline auto injector is administered and they improve

A

Yes

Should always call an ambulance so they can be monitored

151
Q

What can IV salbutamol cause

A

Hyperglycaemia

152
Q

How many cigarettes a day does someone need to smoke to be given the higher dose patch

A

10+

153
Q

How many cigarettes a day does someone need to smoke to be given the higher dose patch

A

10+

154
Q

How long should a child stay home with whooping cough

A

3 weeks after cough started

5 days after started antibiotics

Pre-reg (27 decks)

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