Respiratory Flashcards
Acute asthma (asthma attack) moderate details
- peak flow > 50%
- can complete full sentences
- SpO2 > >92%
- RR > > 30 (5+ years)
- RR > > 40 (1-5 years)
Acute asthma severe details
- peak flow 33-50%
- cant complete full sentences
- RR > > 25 (adult)
- RR > 30 (5+ years)
- RR > 40 (1-5 years)
- HR > 125 bpm (5+ years)
- HR > 140 bpm (1-5 years)
Acute asthma life - threatening details
- peak flow < 33%
- SpO2 < 92%
- cyanosis
- silent chest
- altered consciousness
- hypotension
- exhaustion
Acute asthma moderate adults management
- home or primary care - hospital if inadequate response
- tx = high dose SABA (10 puffs) via PMI and spacer
Acute asthma severe/life threatening adults management
- hospital immediately
- tx = high dose SABA via oxygen driven nebuliser +/- nebulised ipratopium
- life threatening with poor response to initial therapy = IV aminophyllin
- all patient = oral prednisone (40mg 5 days) - if inappropriate = IV hydrocortisone or IM methylpred
- Hypoxaemic = supplementary O2 (maintain between 94-98%)
Acute asthma children 2 years and older severe/life threatening management
- hospital ASAP (O2 in life threatening of SpO2 <94%)
- 1st line = SABA via oxygen driven nebuliser
- 3 days oral pred
- poor initial response to B2 agonist = add nebulised ipratropium
- poor response to 1st line = IV magnesium sulfate
Acute asthma children 2 years and older mild-moderate management
- 1st line = SABA via PMI and spacer - medical attention if not controlled after 10 puffs
- 3 days oral pred
- poor initial response to B2 agonist = add nebulised ipratropium
- poor response to 1st line tx = IV magnesium sulfate
Acute asthma management under 2 years old
- all under 2s admitted to hospital
- mod-severe = immediate oxygen and trial SABA
- if needed combine nebulised ipratropium bromide
Chronic asthma lifestyle advice
weight loss, smoking cessation, breathing exercise programmes
Chronic asthma treatment adults
- SABA (salbutamol)
- SABA + low dose ICS (beclamethasone 200mcg BD)
- SABA + ICS + LTRA (montelukast) (NICE)
3.1 SABA + ICS + LABA (fixed or MART e.g. fostair/symbicort) (BTS/SIGN)
4. LABA with/w/o LTRA - can convert LABA and mod ICS to MART
5. increase ICS to high strength OR specialist = theophylline, tiotropium (12+), coral corticosteroids, monoclonal antibodies
Chronic asthma treatment children over 5
- SABA
- SABA + low dose ICS (100mcg BD)
- SABA + ICS + LTRA (NICE)/LABA (BTS/SIGN) - if 12 years plus
- Replace LTRA with LABA - MART if still no change
- increase ICS strength OR specialist = theophylline, tiotropium (12+), oral corticosteroids, monoclonal antibodies
For chronic asthma treatment when should you move to the next step of treatment
if using SABA 3x week, symptoms 3x week, night awakening 1x week, > 1 inhaler per month
Chronic asthma treatment children under 5
- SABA
- SABA + low dose ICS - 8 wk trial before continuing
- if ICS not tolerated= LTRA - SABA + ICS + LTRA
- stop LTRA and refer to specialist
Chronic asthma treatment dropping down criteria
- when asthma controlled for at least 3 months
- regularly r/v patients when decreasing tx
- maintain lowest effective use of ICS - consider reducing every 3 months by 25-50%
What is complete control of asthma
- no day time symptoms
- no night-time awakening due to asthma
- no asthma attacks
- no need for rescue medication
- no limitations on activity including exercise
- normal lung function (FEV and/or PEF > 80% predicted or best)
- minimal side effects from tx
COPD non-asthmatic features treatment
- SABA or SAMA (SABA continued throughout)
- LAMA + LABA - stop SAMA
- LAMA + LABA + ICS - if 1 sev exacerbation or 2+ mod exacerbation per year - if no change after 3 months = back to LAMA + LABA
- theophylline, oxygen therapy, mucolytics
COPD asthmatic features treatment
- SABA or SAMA (SABA continued throughout)
- LABA + ICS - stop SAMA
- LAMA + LABA + ICS - if 1 sev exacerbation or 2+ mod exacerbation per year
- theophylline, oxygen therapy, mucolytics
COPD exacerbation prophylactic treatment
- azithromycin 250mg 3x week
- offer pneumococcal and influenza vaccine
COPD condition description
- progressive and not fully reversible
- persistent respiratory symptoms
- airflow limitation due to a combination of obstructive bronchiolitis and emphysema
- symptoms = dyspnoea, wheeze, chronic cough, regular sputum production
COPD risk factors
- smoking
- pollution & occupational exposures
- genetic factors
COPD rescue pack information
- exacerbation in last year = give rescue pack:
- Oral corticosteroid (usually pred) + Oral Abx (usually amox) - can be amox, doxy or clarithro
- avoid clarithro if pt on prophylactic azithro
Non drug treatment of COPD exacerbation
positive expiratory pressure helps sputum clearance
COPD exacerbation drug treatment
- SAMA/SABA - hold LAMA if SAMA given (increased muscarinic side effects)
- hospital = short course pred (30mg 5 days) and other therapies
- community = short course pred (30mg 5 days) if significant breathlessness
- aminophylline added if inadequate response to nebulised bronchodilators
- oxygen if needed to keep O2 saturation of arterial blood levels in range
Name SABAs
- salbutamol, terbutaline (4 hours)
- 1-2 QDS, 8 puffs max daily, 10 max in acute asthma attack
Name LABAs
- salmeterol, formeterol, vilanterol (12 hours)
SABA/LABA cautions
- diabetes - DKA after IV administration
- can increase risk of arrhythmias
- causes hypokalaemia - increase risk of QT prolongation
- risk of digoxin toxicity due to hypokalaemia
SABA/LABA side effects
- fine tremor
- palpitations
- headache
- seizure
- anxiety
- QT interval prolongation with corticosteroids, diuretics, theophylline
Name SAMAs
Ipratropium
Name LAMAs
Tiotrpium, Aclidinium, Glycopyrronium, umeclidinium
SAMA/LAMA side effects
- antimuscarinic complications (acts on parasympathetic pathway)
- constipation
- dry mouth
- increase ocular pressure - report halos/blurred vision
SAMA/LAMA interactions
- other antimuscarinics e.g. hyoscine, TCAs, solifenacin, tamsulosin
Name Inhaled CorticoSteroids (ICS)
- Beclamethasone, budesonide, ciclesdnide, fluticasone, mometasone
- all BD except ciclesonide (OD)
Beclomethasone (ICS) brands
prescribed by brand because QVAR and kelhale are 2x stronger than the others
ICS precautions
- steroid cards - carry if long term tx with high doses of ICS
- monitor height and weight in children in prolonged tx annually, slow growth = paediatrician referral
ICS side effects
- taste and voice alteration (hoarse voice)
- sore throat/oral thrush (candidiasis) - use spacer and rinse mouth
- paradoxical bronchospasms (mild = prevented by inhalation of SABA, change from aerosol to DPI)
Name LTRAs
montelukast (zafirlukast discontinued)
LTRA side effects and MHRA alert
- Charge-strauss syndrome (eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, peripheral neuropathy)
- MHRA: risk of neuropsychiatric reactions - medical attention if speech and behavioural changes occur
LTRA interactions
- CYP450 inducers = reduces conc of LTRA
- CYP450 inhibitors = increases conc of LTRA
Theophylline narrow therapeutic index
- 10 - 20 mg/L
Check levels: - 4-6 hours after dose
- 5 days after starting tx
- at least 3 days after dose adjustments
Theophylline brands
- DON’T have same bioavailability
- maintain same brand
- prescribe by brand
Theophylline side effects
- vomiting
- tremor
- palpitations
- arrhythmias
- fever reduce clearance
- convulsions
- diarrhoea
- gastric irritation
- insomnia
CNS stimulation
Theophylline and smoking
smoking reduces clearance - if want to stop, adjust dose
Theophylline interactions
- CYP inducers - reduce concentration
- CYP inhibitors - increase concentration
- corticosteroid, SABA/LABA, diuretics = hypokalaemia
What is croup
a viral infection causing a barking cough, a hoarse voice and breathing difficulties
Mild croup treatment
single dexamethasone dose
Moderate to severe croup treatment
- hospital admission
- single dose of dexamethasone or prednisolone orally whilst waiting admission
- if can’t take oral: IM dexamethasone or nebulised budesonide
- severe not controlled by steroids = nebulised adrenaline/epinephrine
What is cystic fibrosis
genetic disorder affecting the lungs, pancreas, liver, intestine and reproductive organs - viscous sputum, chest infections and malabsorption
Cystic fibrosis treatment
- prevent lung infections and maintain lung function
- mucolytic = dornase alfa - aids in clearance of mucus or sputum from lungs
- long-term antibacterial considered to suppress chronic staph. aureus
- nutrition and exocrine pancreatic insufficiency: pancreatin
- monitor patients for liver disease, diabetes and bone density
1st generation antihistamines
- more sedating
- alimemazine, promethazine, chlorphenamine, cyclizine
- alimemazine and promethazine more sedating than chlorphenamine and cyclizine
2nd generation antihistamines
- less sedating
- acrivastine, cetirizine, desloratidine, loratidine, fexofenadine (120mg now OTC)
Antihistamines for nausea and vomitting
- cinnarazine, cyclizine, promethazine
Antihistamines for migraine
buclizine
Antihistamines for occasional insomnia
1st generation, promethazine OTC
Allergy immunotherapy
- allergen vaccines = reduced asthma symptoms and allergic rhino conjunctivitis
- can contain house dust mite, animal dander or pollen extract
- vaccines with bee/wasp venom = reduced risk of severe anaphylaxis
- omalizumab (monoclonal antibody) binds to IgE - when sever persistent allergic asthma not controlled with ICS + LABA. Side effects = churg-strauss syndrome + hypersensitivity reactions
What is anaphylaxis
severe, life-threatening hypersensitivity reaction - immediate hypotension, rapidly developing airway/circulation problems - from allergen
Steps to take with anaphylaxis
- Autoinjector immediately (IM adrenaline/epinephrine)
- call 999 - state anaphylaxis - administer CPR if needed
- Lie down - raise legs - helps blood back into system
- remove trigger if possible
- repeat after 5 minutes if no improvement
- High flow O2, IV fluids if hypotension/shock
- after stabilisation - non sedating oral antihistamine e.g. certirazine, IM or IV chlorphenamine if oral not possible
- Inhaled bronchodilator therapy with salbutamol and/or ipratropium bromide for persisting respiratory problems
Doses of adrenaline injector
- child up to 6 months = 100 - 150 mcg
- child 6 months to 5 years = 150 mcg
- child 6 to 11 years = 300 mcg
- over 12 years = 500mcg
Adrenaline autoinjector MHRA Alert
- 2 autoinjectors prescribed and carried at all times
Which drug should not be stopped abruptly
baclofen
which drug causes narrow-angle glaucoma
tiotropium
Which drug causes acute angle-closure glaucoma
ipratropium
From what age is salmetorol licensed
- 5
- not licensed under 5 years old
Severe asthma vs life-threatening asthma initial management
both SABA (salbutamol) but severe = via pMDi and spacer, life-threatening = via nebuliser
What is the severity of asthma attack if confusion is present
life-threatening
What is hydroxyzine
a sedating antihistamine that is contraindicated in QT prolongation (caution in heart problems)
Which drugs can be used as normal during pregnancy
- SABAs
- LABAs
- oral and inhaled corticosteroids
- sodium cromoglicate
- nedocromil sodium
- oral and IV theophylline
QVAR in comparison to clenil
- QVAR is 2 times more potent than clenil
- QVAR has extra fine particles compared to clenil
Signs of liver toxicity
- Nausea and vomiting
- jaundice
- itching
- abdominal pain
When is azithromycin contraindicated
severe hepatic impairment
