Chapter 3- Respiratory System Flashcards
Why’s inhalation method preferred for drug delivery to the respiratory system
Drug delivered directly to the airways
The dose required is smaller
Side effects reduced
What is complete control of asthma defined as
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
Treatment ladder recommendations for asthma
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
Which asthmatic medications should be held in pregnancy
None
What peak flow value indicated normal lung function
> 80% predicted or best
When can you start to consider decreasing asthmatics treatment
When their asthma has been controlled with their current therapy for Atleast 3 months
What’s should children be Monitored for when starting a steroid for asthma
Growth failure Reduces bone mineral density Adrenal suppression Eyes for cataracts Weight and height for growth
Management of a severe asthma attack
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)
What’s the treatment ladder for COPD
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
What can reduce mortality risk of COPD
Not smoking if a smoker
Weight loss if overweight
Vaccinating against influenza
When are mucolytic drugs useful in COPD
If it is associated with a productive cough
How are COPD flare ups treated
Corticosteroids or antibacterial if an infection is suspected
What are the most effective SABA and why
Salbutamol and terbutaline
As they’re selective unlike ephedrine
What are SABA used for
Immediate relief of asthma symptoms
What’s a risk of using SABA and when is the risk heightened
Hypokalaemia
Heightened when used with theophylline, corticosteroids and diuretic
Also worse when patient is hypoxia
How long does SABA effects last
3-5 hours
Give examples of LABA and its use
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)
How long does LABA effects last
Up to 12 hours
Side effects of b2 agonists (bronchodilator)
Tremor Headache, muscle cramps, palpitations Bronchospasm Tachycardia, arrhythmia MI Sleep disturbances
What’s an example of a SAMA
Ipratropium
Examples of LAMA
Tiotropium
Glycopyrronium
Aclidinium
How long does SAMA effects last
3-6 hours
Caution with the use of SAMA and LAMA
Prostatic hyperplasia
Bladder outflow obstruction
Angle- closure glaucoma (reported with nebulised ipratropium particularly when given with nebulised salbutamol)
Side effects of Antimuscarinic bronchodilators
Dry mouth
Constipation, cough
Headache, dizziness
What’s the CHM advice for the use of LABA
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
How are corticosteroids effective in asthma
They reduce airway inflammation and hence reduce oedema and secretion of mucus into the airway
Examples of inhaled corticosteroids
Beclometasone
Budesonide
Fluticasone
Momentasone
How are inhaled corticosteroids effective in COPD
May reduce exacerbation when given in combination with an inhaled LABA
Common side effects of ICS
Oral thrush
Altered taste
Voice alterations
LRTI Pneumatic in patients with COPD
Why should ICS be prescribed by Brand
They’re not interchangeable
QVAR is twice as potent as Clenil
Forst air is a combination and is also more potent
What’s some unlicensed uses of beclometasone
Easyhaler not liveeee for children under 18 year
QVAR, clenil 200,250 not licensed for children under 12
How can Inhaled corticosteroids distinguish between asthma and COPD
If consistent use and improvement over 3-4 weeks, suggests asthma
How can you manage oral thrush from the use of ICS
Use spacer
Rinse mouth after
antifungal can be used to treat thrush without stopping treatment
How does montelukast work
It blocks the effect of leukotrienes (inflammatory mediators) in the airways
Examples of Xanthines
Aminophylline and theophylline
How are Xanthines used
Used as Antimuscarinic bronchodilator in asthma and stable COPD (not effective in exacerbation of COPD)
When might theophylline have additive effects
When used with beta2 agonists
Can especially exacerbate hypokalaemia
Where is theophylline metabolised and what increased its plasma concentration
Metabolised in the liver.
Heart failure Hepatic impairment Viral infections Elderly Drugs that inhibit it’s metabolism (diltiazem, erythromycin, ciprofloxacin)
What decreased theophyllines plasma concentration
Smokers
Alcohol consumption
Drugs that induce its metabolism (carbamazepine, primidone, phenytoin and phenobarbital)
Theophylline therapeutic range
10-20mg/L
How is aminophylline administered
By very slow IV injections over Atleast 20 minutes as it’s too irritant for IM
Warning signs for theophylline
Toxicity
Uncontrolled asthma
What needs to be monitored with theophylline
Serum potassium
Plasma theophylline concentration
What’s important about prescribing theophylline and aminophylline
Maintaining the same brand
What’s croup and how is it treated
Infection in the upper airway that blocks breathing and causes barking cough
Usually self limiting but can give single dose corticosteroids (dexamethasone)
What’s used in asthma management but ineffective in COPD
Leukotriene antagonist
What do anti histamines have a role in
Nasal allergies Runny nose (rhinorrhoea) Rashes Insect bites Drug allergies Nausea and vomiting Occasional insomnia
How are the new generations antihistamine different to the older generation and why
Newer cause less sedation and psychomotor impairment because they penetrate the BBB only to a slight extent
What’s the first line treatment and route for anaphylaxis reaction
Adrenaline 500micrograms
Via intramuscular route
Same the sedating antihistamines (older gen)
Promethazine
Alimemazine
Chlorphenamine
Hydroxyzine
Name the newer non-sedating antihistamines
Cetirizine Fexofenadine Loratidine Acrivastine Desloratidine Levocetitizine Mizolastine
What’s the rare side effect of all antihistamine
Hypotension Palpitation Arrhythmia EPSA Dizziness Confusion
What do sedating antihistamines have a significant effect on and when should it be cautioned
Antimuscarinic activity
Cautioned in prostatic hyperteophy, urinary retention and susceptibility to angle-closure glaucoma
What symptoms do antihistamines not help with
Nasal congestion
Which antihistamine is taken upto 4 times a day
Chlorphenamine
When should sedating antihistamines be avoided and why
Liver disease
Risk of coma
What should be counselled to be avoided in excess when taking antihistamine
Alcohol
What should be given in an anaphylactic/ angioedema reaction
Adrenaline/ epinephrine (5minute intervals) Oxygen Antihistamine Corticosteroids IV fluids
From what age is chlorphenamine and promethazine licensed to be sold OTC
6 and above
What risk is hydroxyzine been associated with and what did the meds review conclude to minimise the risk
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
Name some mucolytics and how are they used in COPD
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)
What age is aromatic decongestant not advised, what can be carried out instead?
Under 3 months
Sodium chloride nasal drops or sunction aspiration
Examples of demulcent preparations and their effect
Glycerol
Simple linctus
Soothing
Examples of expectorants and effects
Guaifenesin
Ipecacuanha
Expel bronchial secretions
OTC cough preparations should not be sold for children under 6 if they contain what?
Antihistamines
Cough suppressant (eg: pholocodiene)
Expectorants (eg: Guaifenesin)
Decongestants (eg: pseudoephedrine)
What’s the duration you can sell OTC cough preparations to 6-12 years old
5 days or less
When should decongestants be cautioned and avoided
Cautioned in patients with diabetes, hypertension, hyperthyroidism
Avoided in patients taking MAOIs
What’s used as a cough suppressant (antitussive)
Codeine
Pholocodine
Dextromethorphan
What PEF would you expect to see for a patient having a severe asthma attack
33%-50%
How is asthma diagnosed
Presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough)
And variable airflow obstruction
How should patients ICS be decreased
25-50% every 3 months to the lowest effective dose
Symptoms of moderate acute asthma attack
PEF 50-75
Increasing symptoms
Symptoms of acute severe asthma attack
PEF 33-50
RR >25/min
HR >110/min
Can’t complete sentences in one breath
What does Fostair contain
Beclometasone and formoterol
What does spiromax and symbicort contain
Budesonide and formoterol
What does seretide contain
Fluticasone and salmeterol
Why should salmeterol not be used for the acute relief or prevention of exercise induced asthma
Long onset of action
Which ICS can be taken once daily
Ciclesonide
Momentasone
What is aminophylline a mixture of
Theophylline and ethylenediamine
When should theophylline be sampled after dose
4-6 hours
What’s the oxygen therapy for severe COPD with hypoxaemia
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
How should self administered adrenaline be used
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)
Adrenaline autojector dose
Adult= 300-500mcg
Child 15-30kg= 150mcg
Contraindications for mucolytics
Active peptic ulceration as it disrupts gastric mucosa
What electrolyte disturbance can occur with the coadministration of salbutamol and theophylline
Hypokalaemia
When do you check theophylline doses when starting and after dose changes
5 days after starting
3 days after dose change
Signs of theophylline toxicity
Vomiting and GI effects
Tachycardia
Arrhythmia, convulsion and hypokalaemia
What medication should daktarin gel (miconazole) not be taking with
Warfarin
How can you manage mild bronchospasm from ICS
Use SABA beforehand
Transfer pMDI to dry powder inhaler
What dose of prednisone would you expect to see for the treatment of an acute asthma attack in an adult
40-50mg for 5 days
Child under 12: upto 3 days
Why electrolyte disturbance is caused from SABA and LABA
Hypokalaemia
What electrolyte disturbance can potentially occur with co administration of theophylline and salbutamol
Hypokalaemia
What PEF would be expected for an adult who is defined as having a severe asthma attack
33-50%
Theophylline side effects
Arrhythmia CNS stimulation Convulsions Diarrhoea GI irritation Headache Insomnia Palpitation Tachycardia Vomiting
How do you inhale steroid inhalers?
Quick and deep
What PEF would you expect to find for an adult who is defined as having moderate asthma attack
50-75%
Who should be given oral prednisolone with asthma
Anyone who’s had an asthma attack
Minimum 5 days
There’s an increased risk of of hypokalaemia when theophylline is taken with which drugs
LOOP diuretics
Thiazide diuretics
Corticosteroids
B2 agonist
How should ICS initially be used when starting
Twice daily (except ciclesonide)
What condition should beta 2 agonist be cautioned with
Diabetes
What inhalvers have extra fine particles
QVAR
Fostair
When should a large volume spacer be used
High dose ICS
Patients under 15
Why might smokers need a higher ICS dose
Current and ex smokers reduces effectiveness of ICS so might need a higher dose
What’s the dose for SAMA
TDS
What’s the dose of LAMA
OD (except Eklira BD)
What steroid dose would you give for a COPD exacerbation
30mg OD for 7-14 days
What’s the most sedating old antihistamine
Promethazine
Alimemazine
Which antihistamine causes QT prolongation
Hydroxyzine
What’s an nsaid antihistamine
Ketotifen
How do decongestants work and when should they be avoided
Narrow blood vessels to reduce inflammation
Avoided in: Heart problems High blood pressure Overactive thyroid Diabetes Pregnant women
How long can nasal decongestant be used and why
No longer than 7 days
Causes rebound congestion
What time should decongestants not be taken and why
Night
They have a stimulant effect
Why’s the sale of pseudoephedrine monitored
Aj be used to make methylamphetamine
What meds should be used for productive cough and which for non productive cough
Productive: expectorants (guaifenesin)
Non productive: suppressant (codeine, pholocodeine, dextromethorphan)
What antihistamine can be used to reduce a cough
Diphenhydramine
What’s the sale limit for products containing pseudoephedrine or epherdine to a person at one time in one transaction
720mg of pseudoephedrine
180mg of ephedrine
What inhalants can be used OTC to help clear catarrh
Menthol, pine oil eucalyptus
When to refer colds and flus
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
When to refer coughs
Lasting > 2 weeks Colour sputum Chest pain Shortness of breath Wheezing Whooping cough or croup Failed medication Recurrent night time coughing
Sore throat OTC treatment options
Simple analgesic
Flubiprofen- NSAID lozenges
Difflam- NSAID
Tyrothricin- antibiotic lozenges
Local anaesthetic- dumbing effect
Demulcent pastilles- lubricating effect
When to refer for sore throats in a community setting
Sore throat lasting more than a week Recurrent blunts of infection Hoarseness for more that 2 weeks Difficulty swallowing Failed medication Carbimazole patients
What age is steroid nasal sprays licensed to be sold otc
18+
OTC products available for topical decongestant
Xylometazoline
Oxymetazoline
What’s the first line OTC antihistamine for hayfever
Loratidine as it’s least likely to cause sedation
What age are nasal decongestant like xylometazoline and oxymetazoline licensed to be sold OTC
12
Why should decongestant be avoided in a few conditions
They increase blood sugar levels, heart rate and muscle tremor
Whats the best assessment for asthma control
Symptoms
What age can peak flow meters be used from
5
How should aminophylline be administered for severe acute asthma
5mg/ kg
Over 20 minutes
What does drying a spacer with a cloth do
It increases the chances of electrostatic charges
What are alternatives for SABA
SAMA- ipratropium
If 12+ years- theophylline or oral b2 agonist (bambuterol)
With asthma treatment, what symptoms will prompt you to step up
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
When should you advice the patient to see the gp if a Saba fails to provide relief for a certain length of time
< 3 hours
What brands contain formoterol
Fostair
Duoresp
Spiromax
Symbicort (18+)
What’s the order of potency in beclometasone inhalers
Fostair (most)
Qvar
Clenil
Other CFC containing beclometasone (least)
What should you do if paradoxical bronchospasm is experienced from ICS
Stop and give alternative
What group of patients might need a higher dose of ICS and why
Current and previous smokers
As it reduced effectiveness of ICS
What are used of LRTI
Chronic asthma
Symptomatic relief of hay fever in asthma
Side effect of LRTI
Churg strauss syndrome- occurs on withdrawal of oral corticosteroids
Zafirlukast (liver toxicity)
When what drugs are given with theophylline it increases risk of hypokalaemia
Loop or Thiazide diuretics
Corticosteroids
B2 agonist
What does theophylline interact with to increase risk of seizures
Ciprofloxacin Quinolone (lowers seizure threshold)- Pd interaction
Example of enzyme inhibitor that increase theophylline levels
Quinolones - pk interaction
What medication causes an increase plasma concentration of theophylline and risk of toxicity
Verapamil/ calcium channel blocker Cimetidine Phenytoin Fluconazole Macrolides
(All enzyme inhibitors)
What medication causes a decrease in plasma concentration of theophylline and is subtherapeutic
St. John’s wort
Rifampicin
Which LAMA can be used in asthma with 1 or more severe exacerbation in the last year
Tiotropium (spiriva respimat)
Uses of antihistamines
Allergies (nasal and skin)
Nausea and vomiting
Insomnia
Emergency anaphylaxis and angioedema
What is allergen immunotherapy and who should it be avoided in
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
What’s the safety concerns regarding desensitising vaccines
Hypersensitivity reactions
Life threatening bronchospasm and anaphylaxis
Must be monitored for 1 hour and cpr readily available
How does adrenaline help on an anaphylaxis reaction
Dilates the lungs to open airways
Constricts vessels to increase BP
Should an ambulance be called if an adrenaline auto injector is administered and they improve
Yes
Should always call an ambulance so they can be monitored
What can IV salbutamol cause
Hyperglycaemia
How many cigarettes a day does someone need to smoke to be given the higher dose patch
10+
How many cigarettes a day does someone need to smoke to be given the higher dose patch
10+
How long should a child stay home with whooping cough
3 weeks after cough started
5 days after started antibiotics
