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