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Respiratory Flashcards

1
Q

4 courses of corticosteroid what risk of complication would patient have?

A

Concerns about osteoporosis
Blood sugar effects, skin thinning, psychiatric reactions, chorioretinopathy

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2
Q

Advantages of the inhalation route

A

Delivers drugs directly to the airways (target organ)
Smaller doses required (than by mouth)
Less side effects ; localised side effects rather than systemic

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3
Q

Pressurised metered dose inhaler (PMDI)

A

Patients can use easily
Difficult to use by children and elderly as you need to co-ordinate; hard hold push button
Spacer devices can be fitted to remove the need for actuation (breathing in)
Effective and convenient use for mild to moderate asthma

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4
Q

Breath acuated inhalers

A

Once you breath in - automatic release of drug
Suitable for adults and older children if they can use it effectively
Mouthpiece is bigger
Must use QVAR autohaler from the side as top has vents (dont block airflow)

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5
Q

Dry powder inhalers

A

Useful in adults and children over 5
Who are unwilling or unable to use pMDI
E.g are accuhaler

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6
Q

Changing from a PMDI to a DPI

A

Patients may notice a lack of sensation in the mouth and throat previously associated with each actuation
Coughing can occur
Advice patients to use carefully
Check technique understanding; often main cause of lack of drug response is poor technique

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7
Q

Spacer devices

A

Removes the need for coordination with PMDI
Allows larger proportion of particles to be deposited and inhaled in the lungs
Larger spaces with one way valves (volumetric) more effective than aero chambers (but their more cheaper, smaller, easy to carry and work just as well)
Not to switch between spacer devices (not interchangeable)

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8
Q

Caring for spacer devices

A

Avoid cleaning more than once a month; as electrostatic charge can affect drug delivery
Clean with mild detergent and allow to air dry without rinsing
Replace every 6-12 months
Inhale from spacer ASAP after actuation (drug aerosol very short lived)
Single dose actuation recommended
Tidal breathing (normal breaths) just as effective as single breath

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9
Q

Nebulisers use

A

Severe acute asthma
Usually given in hospital
Converts a solution of drug into an aerosol for inhalation
Used to deliver high doses of drug to the airways than with standard inhalers

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10
Q

Oral drugs for respiratory drug delivery

A

Used when inhalation not possible or more drug is required
Has more systemic side effects than inhalation
E.g B2 agonists tablets, corticosteroids, theophylline and leukotrine receptors

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11
Q

Parental drugs for asthma

A

Given by injection in severe acute asthma
Given when administration by nebulisation is inadequate or inappropriate
Arrange urgent transfer to hospital if patient treated in community

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12
Q

Chronic asthma

A

Chronic inflammation condition of the airways
Symptoms; cough, wheeze, chest tightness and breathlessness
Symptoms vary in severity and can suddenly worsen provoking asthma attack (can cause hospitalisation)

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13
Q

What is complete control of asthma defined as?

A

No day time symptoms
No night time awaking due to asthma
No attacks
No need for rescue medication
No limitation on activity including exercise
Normal lung function

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14
Q

Reasons for uncontrolled asthma

A

Lack of adherence
Suboptimal inhaler technique
Smoking; active or passive
Seasonal or environmental factors

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15
Q

Lifestyle changes in asthma

A

Weight loss to improve symptoms in overweight patients
Offer stop smoking advice and support
Offer breathing exercise programmes with drug treatmen

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16
Q

General advice for asthma medication

A

After adjusting or starting medications review response to treatment in 4-8 weeks
Adjust dose of ICS maintenance therapy over time, aiming for the lowest dose as possible to maintain effective control
Ensure patients can use device at review and when a new type of device is supplied

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17
Q

Management for asthma

A

Stepwise approach
Aim to stop symptoms
Improve peak flow
Before intimating new drug or adjusting treatment; check diagnosis, adherence / inhalation technique
Eliminate triggering factors for acute attacks
Offer personalised action plan and education to all patients with asthma

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18
Q

Management of asthma in adults 17 years +

A

1) short acting B2 agonist (SABA) e.g salbutamol and terbutaline.
If symptoms >3 weeks, waking up at night, not controlled, exacerbation in last 2 years then..
2) ADD preventer/ maintenance therapy; low dose ICS <400 mcg.
3) ADD LTRA and review in 4-8 weeks
4) ADD LABA and review to stop LTRA or not
5) SABA +/- LTRA and MART
6) increase dose ICS to 400-800, continue with MART or change to fixed dose ICS and SABA
7) increase ICS to >800
8) ADD LAMA or theophylline
Seek specialists advice

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19
Q

What is MART

A

ICS and formetrol together
Not to give SABA on its own as it already contains this
Max of 8 puffs a day
E.g Fostair

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20
Q

Children < 5 years

A

1) Offer SABA
2) 8 week trial of paediatric moderate ICS
Monitor for 8 weeks; if symptoms resolve = something else, if symptoms reoccur within 4 weeks;
2) restart ICS at a paediatric low dose
If symptoms occur beyond 4 weeks of stopping
2) repeat 8 week trial of paediatric moderate dose ICS
3) uncontrolled symptoms of paediatric low dose ICS ADD LTRA
4) if uncontrolled on paediatric low dose of ICS and LTRA, stop LTRA and refer to HCP for investigation

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21
Q

Management of asthma in 5-16 years

A

1) SABA; if short lived wheeze and normal lung function
2) ADD paediatric low dose
3) ADD LTRA and review treatment in 4-8 weeks
4) STOP LTRA and start ICS with LABA
5) change to MART regimen with low dose ICS
6) Increase ICS to moderate 200-400 with MART or change to fixed dose ICS + LABA + SABA
7) professionals advice to consider if considering increase in ICS of 400+
8) ADD theophylline

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22
Q

Decreasing treatment

A

If asthma is controlled for at least 3 months, decrease maintenance therapy
Review patients regularly when decreasing
Maintain patient at lowest possible dose of ICS
Reduce dose every 3 months by 25 to 50% each time
Reduce dose slowly as patients deteriorate at different rates
Only stop ICS completely if patients are using a paediatric or adult dose ICS alone as maintenance therapy and are symptom free.

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23
Q

Exercised induced asthma

A

Indicates poor control
Review regular treatment including ICS
If already on ICS and patient is well and controlled but exercise is a problem ADD another drug
SABA USED IMMEDIATELY BEFORE EXERCISE IS THE DRUG OF CHOCIE

24
Q

Pregnancy and asthma

A

Monitor closely
Must be well controlled to prevent risks to mother and baby
Advice importance of taking asthma meds during pregnancy
Importance of stopping smoking
ALL DRUGS ARE SAFE TO USE as normal

25
Management of moderate acute asthma
Treat at home or primary care setting Increased symptoms, peak flow >50-75%, no features of acute severe asthma
26
Severe acute asthma management
Peak flow 33-50% best/predicted Respiratory rate >25 /min HR >110/min Inability to complete sentences in one breath Hospital treatment Predisnolone
27
Life-threatening acute asthma management
Hospital treatment Leah flow <33% best/predicted, arterial oxygen saturation SPO2 <92% Silent chest, cyanosis, Oier respiratory effects arrhythmias, exhaustion, hypotension, altered conscious Supplementary oxygen given to all hypoxaemic patients to maintain SPO2 94-98 High doses of SABA or nebulisers Prednisolone
28
Selective B2 agonists (SABA)
Causes bronchodilator of bronchi Short acting e.g salbutamol and terbutaline (bricanyl) CI; severe pre-eclampsia Cautions arrhythmias, HYPOkalemia S/e; fine tremor, HYPOkalaemia, palpitations, tachycardia, QT interval prolongation
29
Long acting beta agonists (LABA)
Formetrol, (short onset but long acting, Salmetrol (long acting and long action) Fostair, DuoResp, Sympbicort, spiromox, o breeze Only use for patients who regularly use ICS Inhaled route preferred; oral only who cant inhale and parental for severe/life threatening Caution; arrhythmias, HYPOklaemia, HYPERglycaemia, QT prolongation Interactions with HYPOkalaemia worsened by other pottasium lowering drugs S/e; fine tremor, headaches, palpitations, tachycardia
30
Antimuscarinic bronchodilators
Ipatropium bromide, spiriva, anora ellipita, incruse Short term relief for chronic asthma Ipatropium bromide nebulisers for life threatening asthma all licensed for COPD; not suitable for relief of acute bronchospasm Cautions prostatic hyperplasia S/e dry mouth, cough and headaches
31
Leukotriene receptor antagonists
Montelukast Caution in elderly S/e; abdominal pain, churg Strauss syndrome and hepatoxicity
32
Rules when adding another inhaler
Ensure correct technique by patient to ensure poor results is not due to poor technique Single ingredient preparation first to stabilise Adjust dose of single preparation at one time Adjusted on one then add or change another
33
Theophylline
Replaces smooth muscle of bronchial airways and pulmonary vessels to reduce airway responsiveness Used asthma and severe COPD Not effective in exacerbations of COPD Prescribe by brand CI; CVD, epilepsy, fever, hypertention, peptic ulcer, HYPOkalaemia risk and thyroid disorders Aminophylline is injectable version IV; mixture is 20 x more soluble than theophylline alone
34
Theophylline and smoking
Increases clearance so dose adjustment is required when stopping or starting smoking
35
Side effects of theophylline
Arrhythmias Anxiety Tremor HYPOkalemia HYPERglycaemia HYPERuriciaemia Sleep disorder TOXICITY; fast and sick; vomiting GI effects , tachycardia etc
36
Theophylline range
10-20 mg/L Measure concentration 5 days after starting and 3 days after any dose changes Missed dose after 4 hours; need to conisder should it be taken
37
Theophylline interactions
Increase concentration in; HF patients, elderly, infection, inhibitors, verapamil, quinolones, caffeine, hepatic impairment Decreased concentration smoking, alcoholic or inducers, St John’s, Rifampicin Increased risk of HYPOkalemia; diuretics, corticosteroids and B2 agonist, amiodarone, citalopram, macrolide, lithium, velaflxine Increased convulsion risk as it lowers threshold
38
COPD diagnosis
Post bronchodilator spirometer and history of symptoms Level of severity based FEV1, hx of exacerbation, CAT score etc Other investigations; chest x-ray rule out cancer, FBC (anaemia), BMI Is not reversible only aim to manage
39
COPD management
Smoking cessation; reduced decline in lung function Vaccination; as infections can complicate disease Trial high dose ICS for moderate to severe airflow obstruction SABA can relieve symptoms
40
FEV1
Forced expiratory volume How much air you can force out in ONE second Usually <0.7
41
What two classes of asthmatic drugs shouldn’t be used together
SAMA and LAMA
42
When should emergency packs be prescribed
If had exacerbation in last year and at risk of getting more and are competent in using pack
43
Management of COPD wit
1) SAMA or LAMA 2) If have NO asthma features; ADD LABA plus LAMA 2) If they HAVE asthma features ADD LABA + ICS Addition antibacterial; signs of infections azithromycin used for prophylaxis for those; prolonged/ frequent exacerbation, hospital requiring and sputum production g review 3 months every 6 Look out for anxiety and depression Oxygen alert cards who have episodes of hypercapnic respiratory failure
44
Croup
Barking cough, common in children Mild croup is self-limiting but patients can benefit from dexamethasone treatment Severe croup or mild croup that may cause complications need hospital treatment If not controlled by dexamethasone may need Adrenaline nebulisers
45
Corticosteroids treatment use
Clenin, qvar, pulmicort Reduce airway inflammation ICS used regularly for prophylaxis in asthma and reduce exacerbations Smoking reduces its effectiveness so may need higher doses Use regularly for maximum benefit Combined with LABA e.g Fostair, sybicort Can be given for acute attacks; children under 12 for a 3 day course or 5 day course for adults S/e candidiasis of mouth, hoarseness, throat irrritation
46
Candiadiasis and inhalers
Spacer can reduce risk Rinse mouth with water after inhalation Anti-fungal oral suspensions or gel can be used to treat oral candidiasis without stopping steroid E.g nystatin or miconazole gel
47
Antihistamines
Reduce rhinorrhae and sneezing Prevent urticaria; used rashes, insect bites and stings, drug allergies 2 types; sedating and non sedating
48
Sedating antihistamines
Promethazine Hydoxazine (MHRA QT prolongation, risk CVD, hypokalaemia and bradycardia) Cyclizine Alminemazine Chlorenphenamine More sedating and more antimuscarinic
49
Non sedating antihistamines
Certirizine Loratidine, Fexofenadine Acrivistine Less sedating and less psychomotor effect
50
Caution in antihistamines
Sedating more antimuscarinic Epilsepsy Children and elderly more succeptible to side effects Sedating should be avoided in liver disease, enlarged prostate
51
Side effects of antihistamines
Drowsiness Headache Urinary retention Dry mouth Blurred vision GI distrubances
52
Cystic fibrosis
Genetic disorder affecting lungs, pancreases, liver intestines and reproductive organs Symptoms; pulmonary disease, recurrent infections, sputum viscous, Prevent and manage lung infections lossening thick, sticky mucus from lungs Increase lung function increases life expectancy; optimise lung function Airway clearance, and specialist involvement 1st line Doranase Alfa (mucolytic) or mannitol if other is not suitable Antibiotics for pulmonary infections
53
Mucolytics
For patients with lung disease Facilitate expectoration by reducing sputum viscosity Reduce exacerbations of chronic production g cough Stop if no benefit in 4 weeks Steam inhalation with postural drainage can also be effective Caution in peptic ulceration as it can disrupt gastric mucosal barrier E.g carboceitine
54
Anaphylaxis
Medical emergency Adrenaline auto injectors; Jext, Epipen, Emerade Adrenaline 1 in 1000 IM infection to midpoint outer thigh Repeat every 5 mins if necessary Under 6 and 15 to 30 kg use 150 mcg Child 6 to 12 or small child 300 mcg Adult or child 12-18 give 500 mcg MHRA; carry 2 AA, carer to be trained as well Asthma can increase risk of a severe anaphylactic reaction
55
Red flags for cough
Over 3 weeks Pleuritic Chest pain (sharp pain when breathing deeply) Haemoptysis rusty colour (TB/pneumonia), pink (HF), blood (carcinoma/PE) TB symptoms night sweats, rusty phlegm weight loss, fever Serious features; breathlessness, wheeze, weight loss, fever hypotension, tachycardia
56
COPD and oxygen saturation
Aim 88-92% Lower than asthma To reduce risk hypercapnic respiratory failure
57
Asthmatic oxygen concentration aim
94-98%

Medium Weighted Topics (5 decks)

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