Pharmaceutical Care of Respiratory Patients hospital 2

Question 1

list some diseases that may be affected by drugs used in asthma/COPD or diseases that may affect drugs.

Answer 1

1) Diabetes
2) Cardiovascular disease (watch potassium)
3) Hypertension
4) Prostatic hyperplasia
5) Glaucoma
6) Liver disease, pneumonia, heart failure – reduce theophylline clearance

Question 2

list some symptoms of Severe Acute asthma

Answer 2

1) Severe breath-lessness
2) Tachypnea (abnormally rapid breathing)
3) Tachycardia
4) Silent chest
5) Cyanosis
6) Accessory muscle use
7) Altered conscious-ness
8) Decreased O2 saturations

Question 3

list some Drug-drug Interactions in Asthma/COPD

Answer 3

1) Patients already on theophylline – careful with aminophylline infusions
2) Drugs that lower potassium
3) Theophylline interactions e.g. Lithium, macrolides

Question 4

outline how you would treat the symptoms of Severe Acute asthma

Answer 4

1) Oxygen to maintain SpO2 94-98%
2) β2 agonist bronchodilators
3) Steroids
4) Ipratropium Bromide
5) Magnesium sulphate
6) Aminophylline
7) Leukotriene Receptor Antagonists/Antibiotics- Not indicated in acute asthma

Question 5

describe how you would use a β2 agonist bronchodilator for the treatment of severe Acute asthma

Answer 5

1) high doses act quickly to relieve bronchospasm with few side effects – salbutamol 2.5mg – 5mg can be given “back to back”
2) Can also use repeated doses of inhaler via spacer
3) nebulised route (oxygen-driven)
4) Repeat at 15-30 minute intervals
5) Can be given IV

Question 6

outline the use of Steroids for the treatment of sever acute asthma

Answer 6

1) Prednisolone 40-50mg for at least 5 days
2) Reduce mortality, relapses, subsequent hospital admission and requirement for β2agonist therapy
3) Earlier they are given, better the outcome
4) Steroid tablets are as effective as injected steroids, provided they can be swallowed and retained

Question 7

outline the use of Ipratropium Bromide for the treatment of sever acute asthma

Answer 7

1) Greater bronchodilation than a β2agonist alone, leading to a faster recovery and shorter duration of admission
2) 500 micrograms every 4-6 hours (usually QDS)

Question 8

outline the use of Magnesium sulphate for the treatment of sever acute asthma

Answer 8

1) Bronchodilator when given IV or nebulised

2) 1.2-2g iv infusion over 20 minutes

Question 9

outline the use of Aminophylline for the treatment of sever acute asthma

Answer 9

1) Some patients with near-fatal asthma or life threatening asthma with a poor response to initial therapy may gain additional benefit from IV aminophylline
2) Check levels if taking oral theophylline

Question 10

what parameters would need to be monitored for an Asthma patient

Answer 10

1) PEFR- peak expiratory flow rate (PEFR)
2) Oxygen saturation
3) Heart rate
4) Potassium
5) Blood glucose
6) Serum theophylline

Question 11

what promotional health advice should asthma patients be provided with?

Answer 11

1) Patient should be followed-up and reviewed as soon as possible by their asthma nurse
2) Asthma action plan (PAAP) written/reviewed
3) Other lifestyle advice- e.g. pneumococcal vaccine

Question 12

discuss the counselling advice you would provide to acute asthma patients

Answer 12

1) Assess the exacerbation: trigger factors
2) Optimize treatment:
- compliance and review inhaler technique.
- Consider stepping-up treatment
3) Review self-management education and written action plan:
- Review understanding of how to recognize an exacerbation and what to do

Question 13

who provides the guidance for the treatment of asthma?

Answer 13

1) Guidance from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN)
- Stepwise approach.
- Personalised asthma action plan (PAAP)
- Self-management and inhaler technique

Question 14

with regards to the step wise approach for the management of asthma, what happens at step one

Answer 14

mild intermediate asthma: Inhaled short-acting beta-2 agonists e.g. salbutamol, terbutaline

Question 15

with regards to the step wise approach for the management of asthma, what happens at step two

Answer 15

regular preventer therapy: Inhaled corticosteroids (ICS) e.g. beclometasone, fluticasone

Question 16

with regards to the step wise approach for the management of asthma, what happens at further steps (after 1 &2)

Answer 16

Long-acting beta-2 agonist (LABA), leukotriene receptor antagonist or theophylline, and using a daily corticosteroid tablet.

Question 17

Maintenance and Reliever Therapy are used at step 3 and above . outline what drugs are used at step 3 and what are the doses?

Answer 17

1) LABA and ICS in a combination product- simbicort
2) Maintenance TWICE daily dose
3) Same inhaler can be used as reliever
4) Review treatment plan if use as a reliever regularly

Question 18

what are the side effects of Inhaled Corticosteroids used to treat asthma?

Answer 18

1) Oral candidiasis
2) Dysphonia (difficulty in speaking)
3) Higher doses – more severe side effects

Question 19

what are the side effects of Long acting beta-2 agonists

used to treat asthma?

Answer 19

1) Cardiovascular stimulation
2) Anxiety
3) Tremor

Question 20

what are the side effects of Leukotriene receptor antagonists used to treat asthma?

Answer 20

1) Abdominal pain
2) Thirst
3) Sleep disturbances
4) Headache

Question 21

what are patients on prolonged high-dose ICS at risk of experiencing?

1) what are patients issued with?
2) patients should visit the GP if they experience certain symptoms. list these symptoms.

Answer 21

1) Patients on prolonged high-dose ICS are at risk of systemic side effects
2) Issue steroid treatment card
3) Advise healthcare team if fall ill
4) Visit GP if experience symptoms such as worsening fatigue, muscle weakness, loss of appetite, dizziness etc.
5) Reduce dose gradually

Question 22

discuss the Counselling Points for Asthmatics

Answer 22

1) Know the difference between preventer and reliever
2) Understand the importance of using their preventer inhaler regularly even when they are well
3) Know when their inhaler needs to be changed and how to replace it
4) Don’t waste by inappropriate test pressing
5) Know that using a spacer and mouth rinsing will avoid the most common side effects of inhaled corticosteroids
6) Clean their spacer correctly and often enough
7) Aware of any asthma triggers (e.g. dust mites, pet hair, etc.) and how to avoid them or plan to cope with them
Carry steroid card as appropriate

Question 23

how should a spacer be cleaned and how often should it be done?

Answer 23

Once a month, non-ionic detergent, air dry, replace once visible deposits on spacer wall

Question 24

how would you conduct a medicines optimisation for an asthma patient and what information would you provide to the patient?

Answer 24

1) ensure the Spacer is compatible with device
2) Flag excessive use of reliever medication
3) Ensure the patient understands the “relapsing remitting” nature of asthma.
4) If the patient has a PAAP ( action plan) ensure he or she understands it and is happy to action it when necessary
5) Make sure patients know to go their GP or asthma nurse on the last day of their steroid course if their condition has not improved because further doses may be needed

Question 25

what is the purpose of most treatments for chronic obstructive pulmonary disease (COPD) and what is the only thing that has been shown to slow down the decline of lung function?

Answer 25

1) Purpose of most treatments for chronic obstructive pulmonary disease (COPD) is to control symptoms or reduce the rate of exacerbation
2) Only smoking cessation has been shown to slow the decline in lung function.
3) Effectiveness of treatments to control symptoms will vary among individuals.

Question 26

what is the purpose of a Mucolytic and what is the recommended dosage in COPD ?
- name one mucolytic

Answer 26

1) Increase expectoration of sputum by increasing viscosity
2) Discontinue if no improvement after 4 weeks
3) Carbocisteine capsules 1.5g – 2.25g daily in divided doses

Question 27

a Combination of long-acting muscarinic antagonist and long-acting beta2 agonist are the new Treatments in COPD.

1) name the currently available brands ?
2) when are these new treatments used?
3) how often do they have to be administered?
4) what are the advantages of the new treatments?

Answer 27

1) Combination long-acting muscarinic antagonist and long-acting beta2 agonist : Umeclidinium/vilanterol (Anoro Ellipta) or Aclidinium/formoterol (Duaklir Genuair) or Indacaterol/glycopyrronium (Breezhaler).
2) Used if ICS/LABA declined or not tolerated
3) Once or twice daily administration depending on product
4) Comparative efficacy and long-term safety is unclear
5) Less expensive than combined cost of two inhalers
6) Convenience of one inhaler

Question 28

discuss the use of Roflumilast for the treatment of COPD.

• what is its MOA?
• what does NICE recommend regarding its use?
• what should be monitored?

Answer 28

1) Phosphodiesterase type-4 inhibitor
- Anti-inflammatory
2) Adjunct to bronchodilators for maintenance treatment
3) Only recommended by NICE if part of a clinical trial
4) Causes weight loss- patients should monitor body weight

Question 29

list the parameters that should be measured in COPD patients

Answer 29

1) Breathlessness
2) Oxygen saturations
3) FEV1
4) Exercise tolerance
5) Frequency of exacerbations

Question 30

how would you conduct a medicines optimisation for a COPD patient and what information would you provide to the patient?

Answer 30

1) ensure Spacer is compatible with device
2) Flag excessive use of reliever medication
3) Ensure the patient understands importance of recognising exacerbation
4) Monitor and adjust treatments to optimise therapy
5) Check all efficacious and as per guidelines

Question 31

outline the counselling advice you would provide to a patient suffering with COPD

Answer 31

1) Stress the importance of correct use of maintenance medication.
2) Explain when and how to use inhalers, and demonstrate the correct technique for using them
3) Monitor treatments closely- encourage review
- Reduction in therapy not normally possible
4) Vaccinations
5) Instruct patient to respond appropriately to first sign of an exacerbation
6) May need bone protection with long term steroids

Question 32

what is Pneumonia and how does it differ from bronchitis?

Answer 32

1) Acute respiratory illness affecting distal airways of the respiratory tract and lung parenchyma (i.e. the lower respiratory tract).
2) A leading cause of mortality
3) Differs from bronchitis in having consolidation on x-ray

Question 33

discuss the treatment for the following types of pneumonia :

1) Moderate severity CAP
2) High Severity CAP
3) HAP

Answer 33

1) Moderate severity CAP:
- antibiotic therapy 7-10 days, with a Macrolide and amoxicillin
2) High Severity CAP:
- antibiotic therapy 7-10 days, with Beta‑lactamase stable beta‑lactam and a macrolide
3) HAP:
- antibiotic therapy 5-10 days, hospital policy
- Corticosteroids not necessary in CAP unless they have other conditions that indicate them

Question 34

what parameters would be monitored in patients with Pneumonia

Answer 34

1) Response to antibiotics
2) CRP, temperature, respiratory rate, WCC
3) Keep co-existing conditions stable
4) Monitor renal function
5) Adjust doses if necessary
6) Avoid respiratory depressants
7) Watch interactions e.g. macrolides
8) Oxygen saturations 94-98%

Question 35

discuss the counselling advice you would provide to patients suffering with pneumonia

Answer 35

Symptoms should steadily improve:

1) 1week: fever should have resolved
2) 4weeks: chest pain and sputum production should have substantially reduced
3) 6weeks: cough and breathlessness should have substantially reduced
4) 3months: most symptoms should have resolved but fatigue may still be present
5) 6months: most people will feel back to normal.