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Intreventions 2 > Final Review > Flashcards

Final Review Flashcards

1
Q

Composition of Pulmonary Surfactant

A

Mainly composed of depomitoylphosphatidlycholine (Lecithin) and shinogomyelinand

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2
Q

Surfactant Treatment

A

Most surfactant will be reprocessed and recycled in alveolar type 2 cells

This is why babies only need 1-2 treatment

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3
Q

Common Surfactant

A

Bovine Lipid Extract Surfactant (BLES)

Beractant (Survata)

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4
Q

Surfactant Production in the Body

A

Surfactant is produced in type two alveolar cells at 24 weeks gestation

Surfactant is then stored in the lambellar bodies

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5
Q

When is Surfactant Contraindicated

A

Pulmonary Hemorrhage

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6
Q

BLES Dosing

A

5 ml/kg

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7
Q

Neonatal Aspiration Risk

A

The airway is more anterior and superior putting neonates at a higher aspiration risk

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8
Q

Compliance in Neonates

A

Increased compliance

Cartilage is under developed creating high airway reistance and more collapse in the lower airway

Accessory muscle are under developed so they are more susceptible to failure

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9
Q

Neonate Respiratory Anatomy Compared to Adult

Laryngeal Shape

A

Neonate: Funnel Shape

Adult: Rectangular

Laryngeal soft tissue and lymph nodes which meakes them more susceptible to swelling and injury.

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10
Q

Neonate Respiratory Anatomy Compared to Adult

Shape and Location of Epiglottis

A

Neonate: Long/C1

Adult: Flat C4

large and floppy epiglottis (in infants we are using the miller blade to help move the large floppy epiglottis).

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11
Q

Neonate Respiratory Anatomy Compared to Adult

Resting Poistion of Diaphragm

A

Higher in neonates

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12
Q

Carina Position in Neonates

A

Carina is higher (3rdvertebrae), T4/5 by age 10

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13
Q

Infants Neck Flexion

A

Infants have poor neck flexion = higher obstruction risk

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14
Q

Infants Airway

A

Infant airway is more funnel shaped, narrowest point is cricoid

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15
Q

Neonatal Epiglottis

A

Infant epiglottis is OMEGA Ω shaped, less flexible, more horizontal

Neonate: Long/C1

Adult: Flat C4

large and floppy epiglottis (in infants we are using the miller blade to help move the large floppy epiglottis).

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16
Q

Infants Tongue Position

A

Infants have large tongue with posterior placements

Adults have a porportional tongue size

Larger amounts of lymph tissue = higher obstruction risk

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17
Q

Neonate Respiratory Anatomy Compared to Adult

Thoracic Shape

A

Neonate: Bullet shaped

Adult: Conical shaped

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18
Q

Neonate Respiratory Anatomy Compared to Adult

Laryngeal Shape

A

Neonate: Funnel Shape

Adult: Rectangular

Laryngeal soft tissue and lymph nodes which meakes them more susceptible to swelling and injury.

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19
Q

Neonate Respiratory Anatomy Compared to Adult

Anteroposterior transverse diameter ratio

A

Neonate: 1:1

Adult: 1:2

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20
Q

Neonate Respiratory Anatomy Compared to Adult

Body Surface Area/Body Size Ratio

A

Neonate: 9 x adult

Large heart and belly- increase impedance for tidal volume as the heart is taking up more room

Adult: Normal

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21
Q

Identifing the Patient is Hypoxic

A

Low SO2 and PaO2

PvO2 <35 mmHg

O2 Delivery <8 ml/kg/min

High lactate >2.8

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22
Q

Criteria to Consider SBT

A

Resolution of the disease

Adequate oxygenation

HR ≤ 140 bpm, stable blood pressure, stable cardiac rhythm, no ongoing myocardial ischemia, and no uncompensated shock.

No significant uncompensated respiratory acidosis (i.e. pH < 7.30).

Adequate mentation (GCS >= 13) or tracheostomy in place.

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23
Q

Before you Begin a SBT you need to check oxygenation what measure are you looking at

A

PaO2 ≥ 60mmHg

PaO2/ FiO2 > 150-200 or SpO2 >= 90%, with PEEP ≤ 5-8 cmH2O and FiO2 ≤ 0.4 (or as otherwise described in the regional O2 Protocol).

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24
Q

Initiation of spontaneous breathing trial

A

To perform the SBT, the RRT will place the patient on PSV of 7cmH2O and PEEP of 5 cmH2O.

If Automatic Tube Compensation (ATC) is used, then set PSV to 0.

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25
Q

First 5 min of SBT

A

Terminate the test is any of the below occurs

RR > 38

Rapid shallow breathing index (Tobin ratio) > 105

Sweating, anxiety or change in mental status SpO2 < 90% for > 5 minutes

Signs of distress or paradoxical breathing

HR > 140 bpm or a 20% change

Systolic BP < 90 or > 180 mmHg

New dysrhythmia or myocardial ischemia

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26
Q

After first 5 min of SBT

A

For patients ventilated < 72 hours, continue for 30 minutes.

For patients ventilated > 72 hours, continue the trial for 60-120 minutes.

Monitoring should be done after the first 5 minutes and Q15 there after.

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27
Q

Initiating Mechanical Ventilation Goals

A

FiO2 at 0.60 and then adjust to maintain SpO2 > 90%.

The physician must order a target SpO2

Note: Default values will be SpO2 ≥ 88% and ≤ 92% for patients with obstructive lungs and chronic CO2 retention, and SpO2 ≥ 90% for all other patients.

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28
Q

When does the physician need to be notified of changes to FiO2

A

a. The FiO2 has to be set at > 0.60.
b. The FiO2 has to be increased by > 0.30.

This excludes changes for treatment such as suctioning

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29
Q

Arterial Blood Gas Protocol

PA Catheter

A

Mixed Venous samples will be drawn Q12h in a patient having a PA catheter

It is not mandatory to draw an arterial sample in conjunction with each mixed venous draw.

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30
Q

Weaning Parameters

POINTS OF EMPHASIS

A

Patient should be on PEEP < 8 cm H2 O and F1O2< 0.60.

Patient’s own minute ventilation should not be greater than 12Lpm.

Try to place the pt in sitting position or elevate their head in order to optimize pulmonary mechanics

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31
Q

Rapid Shallow Breathing Index (Tobin Ratio)

A

Rapid Shallow Breathing Index (Tobin Ratio) = f (bpm) / VT (L)).

This ratio is determined after the patient had been breathing spontaneously for one minute.

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32
Q

Infants = 32 Weeks 1st Week of Life

Target blood gas

A

Blood Gas >/= 7.20

PCO2 = 45-55 (40-50 in 1st 48 hours of life)

SpO2= 88-92%

Do not treat metabolic acidosis with hyperventilaion

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33
Q

Criteria for Possible HFV

A

You only need one of these but will probably have more than one

RR > 80 bpm

Vt >5ml/kg

PIP >25 cmH2O

MAP >12 cmH2O AND FiO2 >0.40

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34
Q

Infants = 32 Weeks 1st Week of Life

Order of Weaning

A

Volume (4 ml/kg) or PIP (<18 cmH2O) depending on mode

PEEP and Ti

Rate (5-10 increments until you reach 20)

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35
Q

VAP

A

Ventilator associated pneumonia (VAP) is a nosocomial infection occurring in patients receiving mechanical ventilatory support that is not present at the time of intubation and that develops more than 48 hours after the initiation of that support.

VAP can derive from endogenous bacteria (the baby’s own oropharyngeal flora) or exogenous bacteria (eg: Pseudomonas aeruginosa).

VAP is associated with prolonged hospitalization and increased mortality, especially in the very low birth weight infant.

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36
Q

T-Piece Resusictator

During Resucictation

A

To deliver inspiration - place finger over the PEEP cap.

To deliver expiration - remove finger from PEEP cap.

Inspiratory time is operator controlled. A longer expiratory time is optimal, therefore the PEEP cap occlusion should be limited to approximately 0.5 seconds, regardless of the intended respiratory rate.

To achieve target respiratory rate of 40-60 breaths/minute repeat

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37
Q

Consider Extubation in Neonates When

A

RR > 40 with a set RR= 20 bpm AND

Vt= 4ml/kg with PIP <18 cmH2O AND

MAP 7-8 cmH2O AND

FiO2 <0.30 AND

Patient breathign comfortably, hemodynamically stable, no significant increase in TcPCO2, EtCO2 for 1 hour prior to extubation

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38
Q

Where does the MAC Catheter Attach

A

Attaches to the proximal end of ETT using wye connector, same as inline suctioning

Does not need the diconnection of teh closed system

Surfactant will be dleivered at distal end of ETT reducign the risk for obstruction

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39
Q

Closed Suctioning in Neonates

A

Suction level- 100-120 mmHg

Preoxygenate by setting FiO2 5-10% above current FiO2 for ~20 sec

Insertion catheter and apply suction for 1-3 sec before withdrawal

Pull out the catheter in a straight motion (without twirling) to prevent kinking. Time from insertion to complete withdrawal should not exceed 5 seconds.

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40
Q

ARDSnet Algorithm

ABG

A

Oxygenation: PaO2 55-90 and SpO2 88-95%

Ventilation: pH 7.30-7.45

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41
Q

SUCTIONING ENDOTRACHEAL TUBES: NEONATAL

Open Suction Procedure-What Should You Adjust Suction To

A

Adjust suction to 80-100mmHg and test by kinking tube and reading suction gauge

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42
Q

Primary CPAP Management in the Delivery Room

GA 26-28 Weeks

Principals

A

Maintain optimal lung volume and FRC

In L&D and acute phase avoid CPAP >6 in infants 26-28 weeks

Early surfactant does not mean immediate surfactant rather surfactant should be administers in NICU when possible

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43
Q

Primary CPAP Management in the Delivery Room

GA 26-28 Weeks

What are your first steps

A

Clear airway

Initiate CPAP +5, FiO2 0.30

Dry and Stimulate

Attach pulse ox

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44
Q

Primary CPAP Management in the Delivery Room

GA 26-28 Weeks

You just assessed that the patient is spontaneously breathing

A

Assess that heart rate

If above 100-Move on to next assessment

If below 100-Begin neopuff and NRP

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45
Q

Primary CPAP Management in the NICU

GA 26-28 Weeks

CXR and Blood Gas

A

Pneumothorax-Discontinued CPAP, intubate, early surfactant, drain pneumothorax as indicated

Hypoinflation: Consider increasing CPAP or consider intubation, and early surfactant

Hypercarbia (arterial): Consider incresing CPAP

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46
Q

Primary CPAP Management in the Delivery Room

GA 26-28 Weeks

You just assessed that the patient’s heart rate, what do you assess next

A

Assess WOB and SpO2

Mild WOB and SpO2 within range- Maintain CPAP at +5 and FiO2 at 0.30 and prepare to move to NICU

Moderate or Severe WOB and/or SpO2 not within range- Increase CPAP by 1 (Max 6) and increase FiO2 by 0.10-0.20 to achieve targeted SpO2. Then reass WOB and SpO2 if now mild WOB and SpO2 then mainatin level and move to NICU.

If after you make your changes and then FiO2 is >0.60 or there is severe WOB then consider intubation

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47
Q

Primary CPAP Management in the NICU

GA 26-28 Weeks

Moderate WOB OR FiO2 >0.3

A

Assess interface fit and seal

Assess need for suctioning

Review with dr consider CXR and blood gas

Increase CPAP by 1 with a max CPAP of 6

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48
Q

Primary CPAP Management in the NICU

GA 26-28 Weeks

Mild WOB and FiO2 <0.30

A

Leave CPAP at same level until able to maintain target SpO2 with FiO2 <0.25

SpO2 >92% for 6.24 hours AND FiO2 <0.25 (if no review with dr and increase CPAP). If yes then review histogram

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49
Q

Reviewing Histogram

A

SpO2 >85% for 80% of the time and no significant apneas

No-Optimize CPAP for 2-5 days and optimize caffeine

Yes-Wean CPAP by 1

50
Q

Normal ICP

A

5-15 mmHg

51
Q

Rapid Shallow Breathing Index

Calculation

A

Tobin Score

RR/Tidal Volume

52
Q

Bradycardia is persisting even after CPR

A

Epinphrine

Atropine

Consider pacing

53
Q

Atropine

A

Think bratropine

used for increase vagal tone and primary AV block

54
Q

Epinephrine Dosing

A

0.01 mg/kg and 0.01 ml/mg

Repeat every 3-5 min

55
Q

Suction Levels for Children

A

80-100 mmHg for both open and closed

56
Q

What Happends When Secretions Build Up in the Suction Catheter

A

Increased Resistance

Decreased ability to efectivly remove secretions

Can be due to the fact that we are using too small of a catheter

57
Q

Suction Level for Neonates

A

60-80 mmHg for both closed and open suctioning

58
Q

High Suction Levels

A

Suction flow is proportional to suction level when flow is smooth and laminar

However flow in suction system will be turbulent and disorderly so if suction increases by 50% then flow may only increase by 20-25%

59
Q

Sputum Induction Procedure

A

Do in AM and get 3 samples

If needed can rinse mouth and pretreat with bronchodilator

60
Q

Incentive Spirometry

A

Increases transpulmonary pressure gradient by decreasing Pplat

Inspiration will cause a drop in Pplat due to expansion of the thorax allowing negtaive Palva and more gas to flow into alveoli and lung expansion

61
Q

Medication Calculation

A

(What you want/what you have) x quantity is comes in

62
Q

Lung Protective Strategy

A

Permissive Hypercapnia-PaCO2 of 45-55 mmHg

pH ≥ 7.25

VT~ 4 mL/kg

Peak pressures should be < 25 cmH2O

63
Q

Neonatal ABG Goals

A

pH >7.25

PaCO2 45-55

PaO2 45-65

HCO3 15-18

SpO2 85-92

64
Q

BPD and Mechanical Ventilation

A

Permissvie Hypercapnia

VT4-6 mL/kg

Goal pH ≥ 7.25

Peak pressures < 25 cmH2O

Target lower SpO2 85-94%

Volume-targeted modes tend to work best for BPD.

65
Q

Congenital Diaphragmatic Hernia

ABG Goals

A

pH >7.25

Pre-ductal SpO2 85%, though ideal is 90-95%

66
Q

PPHN

Ventilation Goals

A

Target low to normal PaCO2 (35-40) and pH 7.40-7.45

Hyperoxygenate PaO2 >100mmHg

Nitric Oxide Therapy

67
Q

Cyanotic Defect and Target SpO2

A

Rule of 40s

pH 7.40

PaCO2 40s

PaO2 40s

SpO2 70-80%

žThese mimic in-utero conditions and maintain a PDA

68
Q

Mechanical Ventilation and Harmful Effects on Respiratory Sys.

A

V/Q Mismatching

  • Increase shunt and deadspace
  • Decreased pulmonary perfusion

Ventilator Induced Lung Injury

  • Barotrauma, volutrauma, shear stress, atelectatrauma, biotrauma

​Oxygen toxicity

69
Q

PC CMV Absolute Pressure

Decreased Ti sec

A

Ti tot Decreased

Te Increase

I:E Decrease

Pmean Decrease

70
Q

PC CMV Absolute Pressures

Decreased in Compliance

A

Vt Decrease

Ve Decrease

Ti dyn Decrease

71
Q

PC CMV Absolute Pressure

Increased in PEEP

A

PIP Decrease

Pplat Decrease

Pmean Increased

72
Q

PC CMV Delta Pressure

Decreased Rate

A

Ve Decreased

Te Increases

I:E Decrease

Pmean Decrease

73
Q

PC CMV Delta Pressure

Increased Ti sec

A

Ti tot Increased

Te Decrease

I:E Increased

Pmean Increased

74
Q

PC CMV Absolute Pressure

Increased Rate

A

Ve Increase

Te Decrease

I:E Increase

Pmean Increase

75
Q

VC-CMV

Vt Increased

A
76
Q

PC CMV

Delta Pressures

Resistance Decreased

A

Ti dyn Decreased

77
Q

PC CMV Pressure Control Delta

Increased PC

A

PIP Increased

Pplat Increased

Vt Increased

Ve Increased

Pmean Increased

78
Q

Atelectrauma

A

Caused by the repeated opening and closing of alveoli due to inappropriate PEEP

Usually occurs in dependent area

79
Q

PPV and Renal System

A
  • Urinary output (UO) due to changes in CO
  • Endocrinological Effects
    • Increased ADH release
    • Decreased ANP release
    • Activation of the renin-angiotensin-aldosterone system
  • Abnormal ABGs PaO2 results in decreased renal function and UO
    • Function is dramatically decreased when < 40 mmHg
    • PaCO2 > 65 mmHg decreases kidney function
80
Q

PC CMV Delta Pressure

Decreased Ti sec

A

Ti tot Decreased

Te Increase

I:E Decrease

Pmean Decrease

81
Q

PC CMV Delta Pressures

Increased in Compliance

A

Vt Increase

Minute Ventilation Increase

Ti Dyn Increased

82
Q

PC CMV Absolute Pressure

Decreased Rate

A

Ve Decreased

Te Increases

I:E Decrease

Pmean Decrease

83
Q

PPV-Increase Intrapulmonary Shunt

A

Perfusion will go to gravity dependent areas and ventilation will go to gravity independent areas

The gravity dependent areas will be located on the posterior side when the patient is lying on their back

84
Q

Oxygen Index

A

OI = (FiO2 * MAP *100) / PaO2

If you are using FiO2 as a decimal then times by 100 if you are using it was a whole number then you do not need to multiple by 100

Positively correlated with mortality risk

You want a low OI (the lower the better) with <5 being normal

When you are in the 20 you need to begin to look at things such as ECMO because you lungs can no longer properly oxygenate the blood

85
Q

Biotrauma

A

Due to atelectrauma and volutrauma the lung releases inflammatory mediators

This can result in injury to other organs

86
Q

Volume Support Mode

A

Spontaneous Mode

Pressure Limited

Flow Cycled

Volume Targeted

87
Q

PAV

How to Manipulate Tidal Volume with E Senesitivity

A

A decrease in E sensitivity will increase tidal volume and Ti

Unless the patient is air hungry then they will be trying to breath at a high peak volume and it will cut them off faster= smaller breath

88
Q

What will happen to tidal volume if you decrease the resistance in pressure control

A

Volume will stay the same and Tidy will get shorter

What will happen to tidal volume if you decrease the compliance in pressure control

Decrease TC and Ti dyn and volume will go down

89
Q

Porportional Assist Ventilation

A

Used to assist spontanesou ventilation as the breath that will be delivered is similar to pressure support but the support level if variable and porportional to spontaneous effort

This means that the harder the patient works the more support the vent will deliver - POSITIVE FEEDBACK

90
Q

Porportional Assist Ventilation and E Sensitivity

A

E Sensitivity set at 27% (27% of inspiratory peak flow)

Pressure support patient trigger pressure limited flow cycles (flow cycle=e sensitivity)

You will never get equilibrium on a pressure support breath

91
Q

Mandatory Minute Ventilation

A

There is a set MV and if it is not reached the ventilator will kick and deliver mandory breaths until the set MV has been reached

92
Q

AHS Initiation of SBT

A

PSV of 7 and PEEP of 5 unless there is automatic tube compensation then you put PSV to 0

In first 5 minute monitor tobin score (>105), sweating, anxiety, mental status, SpO2 >90%

If any negative changes occur increase PSV and inform physician

93
Q

Tobin Score

A

Also known as rapid shallow breathing index

= (RR)/ (Vt)

An RSBI < 105 breaths/min/L has been widely accepted by healthcare professionals as a criteria for weaning to extubation.

Whereas patients with RSBI > 105 will have a high chance of failure and require re-intubation.

94
Q

Length of SBT

A

If pt has been ventilated >72 hours continue SBT 60-120 min

If pt has been ventilated <72 hours continue SBT 30 min

Monitoring should be done first 5 min and the Q15 after

95
Q

European Consensus and Delivery Room Oxygenation

A

Oxygen for resusucitation should be controlled via a blender

An initial concentration of 30% oxygen is appriopraite of babies <28 GA

For babies that are 28-10 week use an FiO2 of 21-30

96
Q

European Consensus and Spontaneous Breathing Babies

A

In spontaneous breathing babies stabilize babies with CPAP at 6 cmH2O via mask or nasal prongs

97
Q

European Consensus Saturation Goals

A

Saturation goals should be 90-94%

98
Q

In Labor and Delivery and Acut ephase what should you keep CPAP under

A

<6

99
Q

CPAP Waveforms

A

Variable flow is most desireable and is seen in CPAP system (ex. Arabella)

Sechrist systems will deliver a constant flow

100
Q

SiPAP Machine

A

SiPAP is a brand name

Less expiratory resistance and lower flows due to the flip flop gate which will manage baseline pressure

Delivers stable baseline pressure

Uses the Graesby capsule

101
Q

Arabella System

A

Most common method of NIV (CPAP) with infants

Can use nasal prongs or nasal mask

102
Q

Do you set flow or pressure in CPAP

A

With CPAP set the flow to get the pressure you need (you don’t set pressure because of the leaks)

103
Q

What will happen to the ABG if the baby is crying

A

Will be more acidotic

104
Q

BiPhasic Mode Basic Settings

A

6/9 (FiO2 0.5-0.3)

7/10 (FiO2 >0.5)

Rate: 20

Ti: 1 sec.

Separation of 3 cmH2O

105
Q

Indications of CPAP

A

PaO2 < 50 mmHg when FiO2 >0.60

Minute Ventilation is Adequate

PaCO2 is >50 and pH 7.25

Respiratory Distress

106
Q

Neonatal Respiratory Failure

A

PaCO2 > 60 mmHg

pH < 7.25

107
Q

Pediatric Positive Pressure Devices

Pressure Targeted

A

BiLevel/BiPAP (Pressure Support)

When there is a high WOB we will use pressure support rather than CPAP

108
Q

Pediatric Positive Pressure Devices

Pressure Targeted Advantages

A

Leak compensation

Spontaneous and time modes

109
Q

Pediatric Positive Pressure Devices

Volume Targeted

A

Portable home ventilators

Most devices do not have a pressure support feature

Do not trigger well or support spontaneous breathing

Set up so Vt is greater than physiologic Vt

110
Q

Factors Unique to Pediatric Patients that Promote Complications of NPPV

A

Aspiration-Immaturity of airway protective reflexes

Reflux-Impaired gastroesophageal sphincter function during infancy

Upper Airway Obstruction-Anatomical factors, difficulty clearing secretions, large oral leak, mouth breathing

Agitation-Anxiety, incomplete understanding, developmental disorders

111
Q

PRVC

Compliance Decreases

A

Vt will remain the same so there will be an increase in Pplat an PIP (overall increase in Pmean)

MV will not change because RR and Vt is set

Tidyn decreases and Tistatic will increase, but Titotal does not change

Flow will increase

112
Q

PRVC

Resistance Decreases

A

Pressure will remain the same but flow will change due to the changing airway diameter

Tidyn decreases and Tistatic increases (Titotal does not change)

Peak flow will be directly proportional to resistance but overall flow will not change (and we can not measure)

113
Q

PRESSURE CONTROL VOLUME REGULATED

AS TI DECREASES

A

Titotal will decrease and may decrease to the point where we are no longer meetign equilibrium before exhalation starts

Because Ti total is shorter it means that Te is longer, so I:E will decrease

As Ti decreases PIP will increase in order to deliver set Vt

Because the time that we are dleivering the pressure has decrease there will be a overall decreased in Pmean

114
Q

Pressure Control

Compliance Increases

A

Vt will increase because we can increase the volume delivered at certain pressures, because Vt is changing MV will increase

Tidyn will increase and Tistatic will decrease, but Titotal will not change so I:E will not change

The change in Tidyn will increase flow and decrease Pmean

115
Q

Pressure Control

Resistance Increases

A

The only thing that will change is that your Ti dyn will get longer

Remember as resistance increase your flow will decrease making a longer Ti dyn and a short Ti static

116
Q

Mechanical Ventilation and BPD with a PDA

A

When there is a left to right shunt it can lead to chronic pulmonary edema (BPD) making the baby oxygen dependant

So when the baby cries it will create pressure in their lungs creating a right to left shunt which will decrease saturation, but as soon as the baby relaxes their saturations will improve

117
Q

BPD AND OXYGENATION

A

Supplemental oxygen is the main therapy for infants with BPD but the appropriate target remains controversial

Oxygen saturations are accepted at 85-90% after preterm birth

Keep in mind though that patients with severe BPD usually are <36 weeks which is past the time when ROP is a major concern

For BPD, growth failure, respiratory exacerbations and PPHN however we accept saturations of 92-95%

118
Q

Severe Refractory Hypoxemia in Neonates

A

PaO2 < 50mmHg despite CPAP and FiO2> 0.60

119
Q

Silverman Index

A

The higher the silverman score the high the distress

Score 10=Severe respirtory distress

Score >/=7 Impending respirtroy failure

Score 0 No respirtory distress

120
Q

Long Acting B2 Agonists (LABA)

A

Oxeze® (Formoterol)

Serevent® (Salmeterol)

Onbrez® (Indacaterol)

Streverdi® (Oladaterol)*Not on the market yet

121
Q

LAMA/LABA

A

Ultibro® (Glycopyronnium/Indacaterol)

Anoro® (Umeclidinium/Vilanterol)

Intreventions 2 (19 decks)

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