RESPIRATORY Flashcards
12+, child is small or prepubertal, anaphylaxis?
300mcg
A 7-year-old child has been experiencing symptoms of wheeze on most days of the week, as well as nocturnal symptoms causing
them to wake during the night. A diagnosis of asthma is made.
Which of the following is the most appropriate first-line therapy for this child?
paediatric low dose inhaled corticosteroid maintenance therapy in addition to short-acting beta-2 agonist reliever therapy
cos he’s wheezing, not controlled, blah blah
PREDNISOLONE ACUTE ASTHMA ATTACK?
Child 1 month–11 years
1–2 mg/kg once daily (max. per dose 40 mg) for up to 3 days, longer if necessary.
12+ +adults
40–50 mg daily for at least 5 days.
salbutamol+prednisolone?
corticosteroid, interaction, hypokalaemia!
salbutamol+ibuprofen?
no interaction, calm
- According to the BTS/SIGN Guidelines (2019), when should an inhaled corticosteroid be considered as a preventer therapy in adults?
E. during all stages of the asthma management plan
SYBMICORT TURBOTURBO TURBO HALER?
INHALE QUICK AND DEEP
DPI
theophylline side-effect?
diarrhoea still
trimbow?
beclomethasone
formoterol
glycopyrronium
LABA+LAMA+ICS
WHAT DRUG GLAUCOMA RISK?
T^2
tiotropium
topiramate
Qvar® has extra-fine particles, is more potent than traditional beclometasone dipropionate CFC-containing inhalers and is approximately twice as potent as Clenil Modulite®.
Kelhale alsox2 standard inhalers
COPD, IPRATROPIUM+TIOTROPIUM?
Both not needed, hold the tio temporarily (acute exacerbation, cos LAMA, long acting)
b-blocker monitor?
bp+hr
risk of hyperkalaemia
ace monitor?
k+ levels/renal function
ACUTE ASTHMA
MODERATE
PEAK FLOW?
CAN COMPLETE..?
spO2?
RESPIRATORY RATE
Children 5+?
Children 1-5?
MODERATE
PEAK FLOW? >/= 50%
CAN COMPLETE..? full sentences
spO2? >/= 92%
RESPIRATORY RATE
Children 5+? = 30/min
Children 1-5? = 40/min
ACUTE ASTHMA
SEVERE
PEAK FLOW?
UNABLE TO..?
RESPIRATORY RATE
ADULT?
CHILDREN 5+?
CHILDREN 1-5?
SEVERE
PEAK FLOW? 33-50%
UNABLE TO..? Complete full sentences
RESPIRATORY RATE
ADULT? >/= 25
CHILDREN 5+? >30
CHILDREN 1-5? >40
ACUTE ASTHMA
LIFE-THREATENING
PEAK FLOW?
spO2?
SYMPTOMS? CASHE
LIFE-THREATENING
PEAK FLOW? <33%
spO2? <92%
SYMPTOMS? CASHE CYANOSIS ALTERED CONSCIOUSNESS SILENT CHEST HYPOTENSION EXHAUSTION
ACUTE ASTHMA- ADULTS
MODERATE TREATMENT?
High-dose SABA (salbutamol)- pmi+spacer
Up to 10 puffs
ACUTE ASTHMA- ADULTS
SEVERE/LIFE-THREATENING TREATMENT?
High-dose SABA (salbutamol) via oxygen-driven nebuliser AND/OR nebulised ipratropium
ACUTE ASTHMA- ADULTS
NEAR-FATAL TREATMENT (poor response to initial therapy)?
IV aminophylline
ACUTE ASTHMA- ADULTS
ALL PATIENTS?
Contraindicated?
ALL PATIENTS? Oral prednisolone Contraindicated? IV hydrocortisone OR IV methylprednisolone
ACUTE ASTHMA- ADULTS
What do you give to hypoxaemic patients?
Supplementary oxygen (to maintain spO2 between 94-98%)
ACUTE ASTHMA- CHILDREN
>2 YEARS OLD TREATMENT Life-threatening? 1st LINE? Mild-moderate route? Severe route?
> 2 YEARS OLD TREATMENT
Life-threatening? Supplementary O2 to achieve >94%
1st LINE? SABA (salbutamol)
Mild-moderate? via PMI+spacer ( 10 puffs L? 999)
Severe? via oxygen-driven nebuliser
ACUTE ASTHMA- CHILDREN
> 2 YEARS
Poor response to 1st line?
2nd poor response?
In all cases, give..?
> 2 YEARS
Poor response to 1st line? nebulised SABA+ipratropium
2nd poor response? add in IV magnesium sulfate
In all cases, give..? 3 days oral prednisolone
ACUTE ASTHMA- CHILDREN
<2 YEARS TREATMENT
1st LINE?
POOR RESPONSE TO 1ST LINE?
<2 YEARS TREATMENT
1st LINE?
Immediate oxygen+trial a SABA
POOR RESPONSE TO 1ST LINE?
Combined nebulised ipratropium bromide
CHRONIC ASTHMA- LFESTYLE CHANGES?
WEIGHT LOSS if overweight
SMOKING CESSATION
BREATHING EXERCISE PROGRAMMES
ASTHMA TREATMENT- ADULTS
STEP 1?
STEP 2?
STEP 3?
STEP 4?
STEP 5?
STEP 1? SABA
STEP 2? SABA+ low dose ICS (100mcg/ beclomethasone)
Start ICS if asthma is uncontrolled with just SABA:
>/=3x a week SABA use
>/3x a week symptoms
>/= 1x night-time wakey wakey
>/= x1 inhaler use/month
STEP 3? SABA+ICS+
LTRA- montelukast (NICE)
OR
LABA- salmeterol/formoterol (BTS/SIGN) fixed dose
MART (maintenance & reliever therapy) e.g.
Fostair- beclometasone w/ formoterol
Symbicort/DuoResp Spiromax- budesonide w/formoterol turbohaler/dry powder inhaler
STEP 4? +LABA if not already added
Can be given with/without LTRA
Can convert fixed dose LABA+moderate strength ICS into MART
STEP 5? Increase strength to high strength ICS/initiate specialist: Theophylline Tiotropium Oral Corticosteroids Monoclonal Antibodies
ASTHMA TREATMENT- CHILDREN>5
Same as adults but a few differences…
Step 2- Very low strength ICS?
Step 3- Add
Step 4- Replace?
LABA age?
Step 5- same again. increase ICS strength/specialist..
Tiotropium age?
LEARN SIMILARITIES
THEN
POINT OUT DIFFERENCES
Step 2- Very low strength ICS? Clenil 50
Step 3- LTRA
Step 4- Replace? LTRA w/ LABA if not already on LABA
MART is a shout
LABA 12+
Can’t give LABA+LTRA together in children
Step 5- same again. increase ICS strength/specialist..
Tiotropium age? 12+
ASTHMA TREATMENT- CHILDREN<5
Same again but subtle differences…
STEP 1?
STEP 2?
STEP 3?
STEP 1? Intermitent SABA, PRN?, >1 SABA device/month? Urgent referral!
STEP 2? SABA+low-dose ICS
Started if SABA poor control (>/=x3 symptoms/week, >/=x1 night-time awakening/week)
Use paediatric low dose ICS 8-week trial
ICS intolerated? Use LTRA instead
STEP 3? SABA+ICS+LTRA
Still poor? Shout a specialist!
WHEN DO YOU DROP DOWN?
When asthma has been controlled for at least 3 months
Regularly review when decreasing treatment
Maintain patients at lowest possible dose of ICS (reduce /3months, 25-50% every time)
COMPLETE CONTROL OF ASTHMA? NO…
NO DAYTIME SYMPTOMS NO NIGHT-TIME AWAKENING NO ASTHMA ATTACKS NO NEED FOR RESCUE MEDS NO LIMITATIONS ON EXERCISE NORMAL LUNG FUNCTION (FEV1/PEF >80% predicted/best) MINIMAL SIDE-EFFECTS FROM TREATMENT
FEATURES OF COPD? LIPP
LIMITED AIRFLOW (bronchiolitis+emphysema)
IRREVERSIBLE
PROGRESSIVE
PERSISTENT RESPIRATORY SYMPTOMS
SYMPTOMS OF COPD?
RISK FACTORS?
SYMPTOMS OF COPD? (LABOURED) BREATHING WHEEZE CHRONIC COUGH REGULAR SPUTUM PRODUCTION (carbocisteine key)
RISK FACTORS? SMOKING POLLUTION OCCUPATIONAL EXPOSURES GENETIC FACTORS MAD
COPD TREATMENT
Continue SABA throughout all stages
Never USE SAMA+LAMA together
STEP 1?
STEP 2- NON-ASTHMATIC vs ASTHMATIC?
STEP 3- if severe exacerbation/2+ moderate ones in a year?
STEP 4- non-asthmatic still an L?
SABA THROGH ALL STAGES MATE
STEP 1? SABA/SAMA
STEP 2- NON-ASTHMATIC vs ASTHMATIC?
Non-asthmatic- LABA+LAMA (stop SAMA)
Asthmatic- LABA+ICS
STEP 3- if severe exacerbation/2+ moderate ones in a year?
LAMA+LABA+ICS (stop SAMA)
STEP 4- non-asthmatic still an L after 3 months?
Go back to LAMA+LABA
COPD PROPHYLACTIC ANTIBIOTIC?
AZITHROMYCIN-> x3 a week, 250mg?
OTC is only available for chalmydia
SABA?
Salbutamol
SAMA?
Ipratropium
LABA?
Salmeterol
Formoterol
LAMA?
Tiotropium
ICS?
Beclomethasone
LTRA?
Montelukast
COPD EXACERBATIONS
Exacerbation in last year? Patients need…
Exacerbation in last year? Patients need…
A RESCUE PACK! (Oral corticosteroid+antibiotic)
amoxicillin
doxycycline
clarithromycin- AVOID if taking prophylactic azithromycin (both macrolides)
COPD NON-DRUG TREATMENT?
POSITIVE EXPIRATORY PRESSURE- help sputum clearance
SAMA n LAMA can’t be given same time
BUT
SABA n LABA can be given at same time
COPD EXACERBATIONS- DRUG TREATMENT
WAG1 BRO
SABA/LAMA( withhold…)?
HOSPITALISED?
COMMUNITY?
WHEN DO YOU ADD AMINOPHYLLINE?
OXYGEN?
SABA/LAMA( withhold…) LAMA treatment if SAMA is given
HOSPITALISED? short-course prednisolone
COMMUNITY? short-course prednisolone if significant breathlessness
WHEN DO YOU ADD AMINOPHYLLINE? Inadequate response to nebulized bronchodilation
OXYGEN? If needed to ensure oxygen saturation of arterial blood levels
INHALATION THERAPIES
SABA?
LABA?
DOSE?
SABA? Salbutamol/Terbutaline (4hrs action)
LABA? Salmeterol/Formoterol/Vilanterol (12hrs action)
DOSE? 1-2 puffs up to QDS (8 puffs max. daily)
SABA/LABA CAUTIONED IN/RISKS?
DIABETICS (DKA risk esp. after IV)
Risk of arrythmias
Risk of QT pronlongation- hypokalaemia
SABA/LABA SIDE-EFFECTS?
TREMOR
PALPITATIONS
HEADACHES
SEIZURES
ANXIETY
MUSCLE CRAMPS”!!!!!!!!!!!!!!!!!!!!!!!!!!!111
HYPOKALAEMIA (so watch out for digoxin toxicity!)
WHAT OTHER DRUGS CAUSE QT INTERVAL PROLONGATION?
What is this again? Lol- extended interval between heart contracting and relaxing.
CORTICOSTEROIDS
DIURETICS
THEOPHYLLINE
SABA/LABA…
SAMA?
LAMA?
SIDE-EFFECTS?
INTERACTIONS?
SAMA? Ipratropium
LAMA? Tiotropium/Aclidinium/Glycopyrronium
SIDE-EFFECTS? antimuscarinic complications
Constipation
Dry mouth
halos/blurred vision? :(
INTERACTIONS? Other antimuscarinic drugs
Hyoscine
Anti-depressants
Solifenacin
INHALED CORTCOSTEROIDS
EXAMPLES? DOSE? MUST BE PRESCRIBED? STEROID CARDS? MONITORING IN CHILDREN?
EXAMPLES? Beclometasone/Budesonide/Ciclesonide/Fluticasone/Mometasone
DOSE? All BD EXCEPT Ciclesonide (OD)
MUST BE PRESCRIBED? By BRAND
STEROID CARDS? Carry steroid card if receiving long-term treatment w/ high-dose of inhaled corticosteroids
MONITORING IN CHILDREN? Height+weight in prolonged treatment monitored annually. Slow growth- paediatrician referral
INHALED CORTICOSTEROIDS- SIDE-EFFECTS?
TASTE/VOICE ALTERATION
SORE MOUTH
PARADOXICAL BRONCHOSPASM
INHALED CORTICOSTEROID- PARADOXICAL BRONCHOSPASM TREATMENT
MILD?
CHANGE?
MILD? Prevented by inhalation of SABA before ICS use
CHANGE? Aerosol-> DPI
LTRA
EXAMPLES?
MHRA WARNING?
CSS?
INTERACTIONS?
EXAMPLES? Montelukast
MHRA WARNING? Risk of neuropyschotic reaction (speech//behavioural changes?)
CSS? Churg-Strauss Syndrome, keep an eye out for.. Eosinophilia Vasculitic rash Worsening pulmonary symptoms Cardiac complications Peripheral neuropathy
INTERACTIONS? LTRA is a CYP450 enzyme substrate so…
CYP inducers will reduce LTRA conc.
CYP inhibitors will increase LTRA conc.
THEOPHYLLINE- HIGH-RISK DRUG!!! :O
THERAPEUTIC RANGE? Phyll ;)
WHEN DO YOU CHECK PLASMA LEVELS?
PRESCRIBE+MAINTAIN SAME?
THEOPHYLLINE? PHYLL ;)
THERAPEUTIC RANGE? 10-20mg/L (same as PHenytoin)
WHEN DO YOU CHECK PLASMA LEVELS?
4-6hrs after dose
5 days after starting treatment
At least 3 days after a dose adjustment
PRESCRIBE+MAINTAIN SAME? Brand (due to different bioavailability)
THEOPHYLLINE- SIDE-EFFECTS?
VOMITING TREMOR PALPITATIONS ARHYTHMIAS DIARRHOEA
THEOPHYLLINE- INTERACTIONS?
SMOKING- cessation will INCREASE theophylline conc, dose adjustment needed
FEVERS- reduces clearance of theophylline
CYP ENZYMES- inducers (reduce conc) & inhibitors (increase conc.)
HYPOKALAEMIA- corticosteroids/SABA/LABA/diuretics
CROUP- TREATMENT
MILD?
MODERATE-SEVERE?
MILD? Single dexamethasone dose oral
MODERATE-SEVERE? Hospital..
Single dose of dexamethasone/prednisolone oral whilst waiting
Can’t take oral? IM dexamethasone/nebulised budesonide
Steroids an L? Nebulised adrenaline/epinephrine
ANTIHISTAMINES, allergies
Different forms used?
Oral
Topical
Nasal
Eye drops
ANTIHISTAMINES
1st generation? (more sedating) APC^2
2nd generation? (less sedating) CAt-DF
1st generation? (more sedating)
alimemazine/promethazine/chlorphenamine/cyclizine
(alimemazine+promethazine MORE sedating than chlorphenamine+cyclizine)
2nd generation? (less sedating)
acrivastine/cetirizine/loradatine/desloratadine/fexofenadine
(fexofenadine 120mg now OTC)
ANTIHISTAMINES- TREATMENTS
N&V?
MIGRAINE?
INSOMNIA (occasional)?
N&V? Cinnarizine/Cyclizine/Promethazine
MIGRAINE? Buclizine
INSOMNIA (occasional)? prom/cyc/chlor
ALLERGEN IMMUNOTHERAPY
What is it?
What about vaccines containing bee/wasp venom?
What is it?
Uses allergen vaccines containing house dust mite/animal dander/pollen extract to reduce symptoms of asthma and allergic rhinoconjunctivitis
What about vaccines containing bee/wasp venom?
Reduces risk of severe anaphylaxis
OMALIZUMAB
WHAT IS IT?
USED AS ADDITIONAL THERAPY IN INDIVIDUALS W/?
SIDE-EFFECTS?
WHAT IS IT? A monoclonal antibody that binds to IgE
USED AS ADDITIONAL THERAPY IN INDIVIDUALS W/? Proven IgE-mediated sensitivity to inhaled allergens, when severe persistent allergic asthma can’t be controlled adequately with ICS+LABA
SIDE-EFFECTS? Churg-Strauss syndrome+hypersensitivity?
ANAPYHYLAXIS- very important!
What is it?
Severe, life-threatening hypersensitivity reaction- airway/circ problems, caused by allergen (food/drugs/venom/latex)
SOMEONE HAS HAD AN ANPAHYLACTIC REACTION.. WHAT DO YOU DO?!
1) Use auto-injector immediately (IM adrenaline/epinephrine)
2) Immediately call 999+state anaphylaxis- CPR if need be
3) Lie down+raise patient’s legs- blood flow
4) Remove the trigger
5) Repeat after 5min interval if no improvement :(
HOSPITAL…
6) High flow oxygen asap
7) IV fluids- hypotension/shock
8) Patient stabilized? Give non-sedating oral antihistamine, e.g. cetirizine
9) Oral L? Give IV/IM chlorphenamine
Persistent respiratory problems? Consider inhaled SABA w/without ipratropium
ANAPHYLAXIS- DOSES /5minutes?
CHILD UP TO 6 MONTHS? 6MONTHS-5 YEARS? 6-11 YEARS? >12 YEARS?
MHRA SAFETY?
CHILD UP TO 6 MONTHS? 100-150mcg 6MONTHS-5 YEARS? 150mcg 6-11 YEARS? 300mcg >12 YEARS? 500mcg
MHRA SAFETY? 2 autoinjectors should be prescribed+carried at all times!
CYSTIC FIBROSIS
What is it?
Genetic disorder of lungs/pancreas/liver/intestine/rpr organs
Viscous sputum/chest infections/malabsorption
CYSTIC FIBROSIS- AIM OF TREATMENT?
Prevent lung infection+maintain lung function
CYSTIC FIBROSIS- DIFFERENT TREATMENTS
MUCOLYTIC?
LONG-TERM ANTIBACTERIAL?
NUTRITION/EXOCRINE PANCREATIC INSUFFICIENCY?
MONITOR FOR..?
MUCOLYTIC? Dornase alfa (aids clearance of mucus/sputum from lungs)
LONG-TERM ANTIBACTERIAL? Suppresses chronic Staph. Aureus, give oral anti-staph
NUTRITION/EXOCRINE PANCREATIC INSUFFICIENCY? Pancreatin (replaces pancreatic enzymes)
MONITOR FOR..? Liver disease/diabetes/bone density
Start ICS if asthma is uncontrolled with just SABA when? 1) 2) 3) 4)
1) >/=3x a week SABA use
2) >/3x a week symptoms
3) >/= 1x night-time wakey wakey
4) >/= x1 inhaler use/month
Fostair?
beclometasone w/ formoterol
Symbicort/DuoResp Spiromax?
budesonide w/formoterol
turbohaler/DPI
INHALER DEVICES, METHOD
PAEDIATRIC ASTHMA, LABA+LTRA? (NICE)
Not given together, LTRA+ replaced with LABA
Adults it’s calm
adult asthma sab+ics+laba?
with/without LTRA, at discretion i guess
EASI BREATHE BREATH-ACTUATED pMDI pMDI w/spacer respimat technique?
SLOW & STEADY, 4-5 SECONDS
DPI
technique?
QUICK & DEEP, 2-3 seconds
pMDI w/ spacer weird alternative?
breathe in and out through your mouth, slowly and steadily
WHEN DO YOU BREATHE IN AND PRESS THE INHALER AT THE SAME TIME?
pMDI!
DOSE COUNTER? BAI? DPI? pMDI? pMDI w/ spacer?
BAI? sometimes
DPI? YES
pMDI? sometimes
pMDI w/ spacer? sometimes
BAI CLEANING?
clean plastic case, never put metal canister in water
DPI CLEANING?
WIPE MOUTHPIECE WITH DRY CLOTH ONLY, NEVER USE WATER TO CLEAN DPI
pMDI CLEANING?
NEVER PUT IN WATER
HOW DO YOU CLEAN SPACER?
USE WARM WATER, MILD DETERGENT, RINSE AND AIR DRY, DO NOT USE A CLOTH/TOWEL
CLEAN ONCE A MONTH
REPLACE EVERY 6-12 MONTHS
spiriva drug?
tiotropium
serevent accuaherl drug?
salmeterol
atrovent pmdi drug?
ipratropium
schedule 3 safe cus
temazepam
buprenorphine
- Inhaled combination therapy for chronic pulmonary obstructive disease refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA), and inhaled corticosteroids (ICS). Trelegy Ellipta is a single LABA/LAMA/ICS combination inhaler.
Which patient below is suitable for treatment with a Trelegy Ellipta inhaler?
A. A patient requiring initial empirical treatment to relieve breathlessness and exercise limitation.
B. A patient currently using a LABA/ICS treatment who has been increasingly breathless recently due to worsening heart failure.
C. A patient currently using a LABA/LAMA treatment who has had one severe COPD exacerbation requiring hospitalisation within the last year.
D. A patient currently taking LABA/ICS treatment who has had one moderate COPD exacerbation within the last year.
E. A patient previously taking LABA/LAMA treatment whose symptoms have not improved after a 3 month trial of Trelegy Ellipta treatment.
Answer: C (A patient currently using a LABA/LAMA treatment who has had one severe COPD exacerbation requiring hospitalisation within the last year.)
• Patients taking LABA+ICS or LABA+LAMA who have a severe exacerbation (requiring hospitalisation) should be offered LAMA+LABA+ICS according to the NICE guideline [NGllS) on COPD.
• A - Use short-acting bronchodilators, as necessary, as the initial empirical treatment to relieve breathlessness and exercise limitation.
• B - Before starting LAMA+LABA+ICS, conduct a clinical review to ensure that the person’s day-to-day symptoms that are adversely impacting their quality of life are caused by COPD and not by another physical or mental health condition.
• D - Consider triple therapy for patients who have 2 moderate exacerbations within a year.
• E - If symptoms have not improved after a three month trial, stop LAMA+LABA+ICS and switch back to LAMA+LABA
COPD
when do you step up to triple?
1 severe 2 moderate exacerbations or or QoL is peak
- You receive a prescription for a spacer for a 14-year-old boy with a chest infection. He has been prescribed a salbutamol inhaler to help with wheezing.
Which of the following statements regarding the use of spacers is INCORRECT?
A. A spacer device increases the velocity of the aerosol and subsequent impaction on the oropharynx, reducing local adverse effects and reducing the amount of systemic absorption.
B. A spacer device reduces the need for coordination between actuation of a pressurised MDI and inhalation.
C. After washing a spacer device, it should be allowed to dry in air without rubbing dry with a cloth.
D. Spacer devices are particularly useful for infants, children with poor inhalation technique, or for nocturnal asthma.
E. Spacer devices should be replaced every 6-12 months.
A (A spacer reduces the velocity. All other statements are correct.)
