Chronic obstructive pulmonary disease Flashcards
Symptoms of COPD
dyspnoea, wheeze, chronic cough, regular sputum production
Main risk factor for developing COPD
smoking
Risk factors for developing COPD
Smoking, environment, occupational exposure, genetic factors (hereditarty alpha 1 antitrypsin deficiency), poor lung growth during childhood
Non drug treatment of COPD
- smoking cessation
- pulmonary rehabilitation
- breathing techniques
- Diet (to lower BMI)
What should all patients with COPD be offered annually?
Flu vaccine
Initial management of COPD
- Short acting bronchodilator SABA/ SAMA
Step up COPD treatment for patients without asthmatic features
- LABA or LAMA (continue SABA alongside but discontinue SAMA if starting a LAMA)
What criteria must a COPD patient (no asthma sx) meet before being initiated on ICS?
- Patients who are on a LABA/LAMA and require hospitilisation
- at least 2 moderate exacerbations (requiring systemic steroids / antibiotics) within a year
How often should COPD patients on ICS be reviewed?
Annually
If a patient has COPD (no asthma sx) and is on LAMA and LABA who feels their symptoms adversely effect their QOL what can be trialled?
ICS for 3 months
What can be offered as step up treatmetn for COPD patients with asthmatic symptoms
LABA + ICS
- if patient on a LABA + ICS has a severe exacerbation or 2 moderate exacerbations in a year add in a LAMA
What prophylactic antibiotic can be used in COPD?
Azithromycin ( used in patients who are non smokers and have had all other treatment options and continue to have frequent exacerbations)
What tests should be carried out before starting prophylactic Azithromycin in COPD patients?
ECG (rule out QT prolongation) sputum culture sensitivity CT scan of thorax LFTs at baseline review at 3 motnhs, 6 months
What drug can be used as an add on therapy to bronchodilator therapy in patients with severe COPD + chronic bronchitis?
Roflumilast
When should oral theophylline be used in COPD managment?
Only after a trial of SA + LA bronchodilators / if patient unable to use inhaled treatment
How is a severe COPD exacerbation managed?
- Rescue packs with an antibiotic + steroid
- prophylactic azithromycin can be continued during an acute exacerbation
- SABA via a nebuliser (withold LAMA if SAMA given)
- short course of pred 30mg
- Aminophylline should only be used as add on therapy if there is inadequate responce to nebulised bronchodilators
Example of a respiratory stimulant used in acute respiratory failure
Doxapram
What is the target concentration of oxygen in patients with carbon monoxide poisoning or in cardiac arrest?
Highest possible
If a patient is at risk of hypercapnic respiratory failure, what oxygen target should we aim for?
88-92%
Exmaple of a LAMA MDI
Spiriva ( tiotropium) Respimat 2.5mcg 2puffs OD
Example of a LAMA DPI
Eklira (aclidinium) Genuair - 1puff BD
Incruse (umenlidinium) Ellpipta - 1puff OD
Spiriva (tiotropium) handihaler 1puff OD
Seebri (glycopyrronium) Breezhaler - 1 ouff OD
Example of LABA MDI
- Atimos (Formoterol) MDI 1 puff BD
- Striverdi (Olodaterol) Respimat 2 puff OD
LABA DPI examples
Oxis (formoterol) 1 puff OD
Fomoterol easyhaler 1puff BD
LAMA + LABA MDI examples
Spiolto (tiotropium + olodaterol) respimat 2 puff OD
LAMA + LABA DPI example
Duaklir (aclidinium / formoterol) Genuair 1 puff BD Anoro Elipta (umeclidinium / vilanterol)
LAMA + LABA + ICS MDI therapy examples
1) Fostair (beclomethasone /formertol) PLUS spiriva respimat
2) Symbicort (budesonide / formoterol) mdi PLUS spiriva respimat
LAMA + LABA + ICS DPI therapy examples
1) Symbicort turbohaler + Eklira Genuair (aclidinium)
2) Revlar (fluticasone furoate / vilanterol) PLUS Incruse elipta
LAMA + LABA + ICS all in one inhaler examples
1) MDI - trimbow (beclomethasone, glycopyronium + formoterol) 2 puffs BD
2) DPI - Trelegy (fluticasone, umeclidinium + Vilanterol) 1 puff OD
How should a patient be counselled to breathe with MDI?
Long and slow
How should a patient be counselled to breathe with DPI?
Quick and fast
What device can help determine the correct inhaler device?
In-check dial
What may be required to treat croup?
Single dose of Dexamethasone
What is croup?
Childhood condition that mainly affects babies - characterised by a barking cough
What drug class is ipratropium and how long is its duration of action?
a short acting muscarinic antagonist (SAMA)
with maximal effects between 30-60mins. It has a sloweronset of action to short acting beta agonists (SABA). Durationof action = 3-6 hours.
Examples of LAMAs
Tiotropium, aclidinium glycopyrronium and umeclidinium
Duration of action of tiotropium
24 hours
What conditions are LAMAs cautioned in?
-Prostatic hyperplasia and bladder outflow obstruction
worsened urinary retention reported
-Angleclosure glaucoma n bulised mist can
precipitate/worsen. Use a mouthpiece rather than a mask
What tiotropium inhaler had an MHRA alert warning in may 2018?
Braltus - risk of inhalaton of capsule if placed in the mouthpiece of the inhaler
What age are salbutamol syrup and tablets not licensed for use in?
<2 year olds
Injection and infusion of salbutamol is not licensed for what age group?
<12 years
MHRA warning for corticosteroids (inhaled + systemic)
Rare risk of central serous chorioretinopathy. Patients should report ant blurred vision / visual disturbances
Side effects of inhaled corticosteroids
oral candidiasis, voice alteration, taste alteration, headache, growth suppression in children, glaucoma
How can the risk of candidiasis be reduced wiht ICS?
Wash mouth before and after use
If a patient experiences paradoxical bronchospasm with ICS what does the BNF suggest?
discontinue and an alternative therapy should be considered
If a child is using ICS what should be monitored?
Height and weight annually
What is the MHRA warning regarding QVAR and Clenil modulite?
They are not brand interchangable (differing bioavailibilities) as QVAR has extra fine particles and is more potent than traditional beclomethasone ( twice as potent as Clenil)
What is the only OD ICS?
Ciclesonide
Mepolizumab is a biological medicine used in eosinophilic asthma - how are these prescribed / dispensed?
By brand name (record batch number and name after each administration)
What is the MHRA warning associated with LTRA?
Risk of neuropsychiatric reactions (speech impairment and OCD)
What drug class is Nedrocromil sodium?
Mast cell stabiliser
Example of a phosphodiesterase 4 inhibitor used in asthma as bronchodilator
Roflumilast
How should Aminophylline / Theophylline be prescribed
By brand name
Therapeutic range required for theophylline
Therapeutic range 10 20mg/L (sometimes 5 15mg/L is effective)
In what instances can Theophylline level be increased ?
congestive HF, hepatic impairment, viral infections, drugs p450 inhibitors
In what instances can theophylline levels be decreased?
smokers and by alcohol consumption - care and monitoring required during smoking cessation, drugs p450 inducers
Theophylline toxicity symptoms
Vommiting, agigtation, restlessness, dilated pupils, sinus tacycardia, hyperglycaemia
when is taking a theophylline level essential?
When giving IV loading dose
How long after the IV dose should a theophylline level be taken?
4 - 6 hours
What electrolyte derrangment can occur from theophylline?
Hypokalaemia
