Respiratory Flashcards
in asthma when would you add in an ICS?
- using reliever or symptomatic at least 3 times a week
- night time symptoms at elast once a week
- asthma attack requiring steroids in last 2 years
in ashtma should you refer someone using more than one inhaler every 2 months?
no - refer when using more than one inhaler a month as shows uncontrolled asthma
when starting a preventer how many times a day should the pt use it?
BD then step down to OD if well controlled
what’s the next step when someone is already on SABA + ICS?
name 2 of these drugs
LABA + low dose ICS
formoterol, salmeterol
after adding LABA with ICS what’s the next step in therapy? (3 parts)
Step 3 part 1 - no repsonse: stop LABA - increase ICS dose
Step 3 part 2 - if benefit but control still inadeqaute continue LABA and increase ICS
Step 3 part 3 - if benefit but control still inadequate continue LABA - trial LTRA, LAMA, or SR theophylline
what does step 4 of asthma pathway look like?
what are the options the additonal drug be?
add forth drug + high dose ICS
1. SR Theophylline
2. LAMA
3. LTRA - montelukast
4. oral B2 agonist tablet - bambuterol
what do you add in at step 5 of the asthma pathway?
oral pred - single dose am then gradually step down
how do you know if vilanterol is being used for COPD or asthma? (combination inhalers)
if used with umeclidinium = COPD
if with fluticasone = asthma
out of the 2 LABA for asthma, which one can be use as a releiver and why can’t the other one be used in this way?
formoterol = short onset + long action
salmeterol = long onset + long action so not for acute releif
what are the main 5 SE of beta agonists?
- tremours
- tachycardia
- hyperglycaemia
- hypOkalaemia
- CV effectd (prolonged QT) - caution in hypothyroidism
what ICS has OD dosing? (the rest are usually BD)
ciclesonide = OD
how many weeks must a pt take ICS before seeing effect on asthma control?
3 - 4 weeks
what do you need to remember about the bioequivalance of Qvar and Clenil?
they are not interchangable
Qvar is twice as potent as Clenil as has extra fine particles
what ICS is the more potent than traditional CFC-free inhalers?
Fostair
what are the 3 main SE with ICS?
- hoarse voice
- sore throat
- oral thrush
when dose NICE recommend a spacer should be used?
with high dose ICS and pt under 15yrs
what should you do if pt expereicnes paradoxical bronchospasam and what if mild bronchospasam?
paradoxical - stop and give alternative
mild - use SABA beforehand or transfer from pMDI to DPI
what do leukotriene receptor antagonists do?
by blocking the action of leukotriene on the cysteinyl leukotriene receptors in the lungs and bronchi - reduces bronchocontriction and inflammation
what are the 2 SE to look out for with leukotrine receptor antagonists, what are the symptoms?
- Churg strauss syndrome - occurs on withdrawal or reduciton of oral corticosteroid
signs = eosinohillia, rash, peipheral neuropathy, worsening pulmonary symptoms - Zafirlukast (liver toxicty) - pt to report signs of liver toxicty (N&V, jaundice, itching, abdo pain)
what class of drug is theophylline?
Xanthina bronchodilator
why is aminophylline give IV and not IM?
becuase it’s 20x mroe soluble and too irritant to give IM
theophylline has a narrow therapeutic index - what levels do we look for and when do we take the sample?
10 - 2-mg/l
sample 4 -6 hrs after dose
what factors can increase and decrease the concentration of theophylline?
increase = heart failure, hepatic impairment, viral infections, elderly, enzyme inhibitor
decrease = smokers, alcohol, enzyme inducers
is theophylline bioequivalent?
no - prescribe by brand!
what are the signs of theophylline toxicity (fast and sick)?
vomitting and GI effects
tachycardia, agitation
arrhythmias, hypOkalaemia
what are the 4 types of interactions with theophylline you need to be aware of?
- increased risk of hypOkalaemia (loop/thiazide diuretics, corticosteorids, B2 agonists)
- increased risk of convulsions with ciprofloxacin (quinolones) as they lower seizure threshold
- increased plasma conc and risk of toxicity with CCB, fluconazole, phenytoin, macrolides (enzyme inhibitors)
- reduced plasma conc is subtherapeutic - st/ johns wort, rifampicin
what is given via nebuliser in acute emergencies of asthma?
salbulatmol/terbulatine
can add ipratropium bromide if needed
NB PO pred or IV hydrocortisone given for at least 5 days in adults
outline the COPD treatmetn pathway (step 1, step 2 with FEV >50% and <50%, and step 3 persistent exacerbation/breathlessness)
step 1 = SABA or SAMA
step 2 = if exacerbation or persistent breathlessness = FEV >50% add LABA, then LABA/ICS or LAMA. If FEV <50% add LABA/ICS or LAMA
step 3 = triple therapy = LABA/ICS + LAMA
in COPD if symptoms persistnet of pt unable to use inhaler what therapy could you try?
MR theophylline/amiinophylline
name 3 LABAs used in COPD
- olodaterol
- indacterol
- vilanterol
name a short acting muscarinic used TDS in COPD ipratropium
name 3 LAMAs used OD in COPD
glycopyronium
umeclidinium
tiotropium
when are antimuscarinicns cautioned?
in prostatic hyperplasia
risk of acute angle closure glaucoma with nebulised ipratropium
what are the 3 parts to treating exacerbation of COPD? (could be 4 parts if poor response to bronchodilators)
- bronchodilator therapy
- IV aminophylline if poor response to nedulised bronchdilator
- short course PO pred (30mg OD for 7 - 14 days)
- antibacterial therapy
when are antihistamines cautioned? (3 cases)
- benign prostatic hyperplasia (urinary retention)
- glaucoma (raised intraocular pressure)
- severe liver impairment (sedation precipitates hepatic coma)
what is hydroxyzine and what are the MHRA warnings associated with it?
a unique antihistamine
warnings = QT prolongation + torsade de pointes
short use only
what allergies can desensitising vaccines be used in? what must be on stand by?
when must you avoid desensitising vaccines?
hay fever unresponsive to other anti-allergy drugs and hypersenstivity to wasp and bee venom
must have CPR immediately avaialble and monitor pt for at least one hour
avoid in:
asthma
pregnancy
children under 5
beta blockers
ACEi
what is the MAb used for allergies?
what Ab does it bind to?
What SE do you need to look out for?
omalizumab
binds to IgE
Churg-Strassus syndrome
how often should you repeat adrenaline if necessary?
every 5 mins
what class of drug may stop pt from responding to adrenaline?
waht’s the alternative?
beta blockers
IV salbutamol
in addition to adrenaline, what other 3 drugs can be used in anaphylaxis?
high flow oxygen
chloramphenamine
hydrocortisone
what’s the MHRA advice regarding epipens?
- prescribe 2 auto-injectors, carry at all times
- pt/carer with allergies trained on how to use
- check expiry dates
what is used in the medical emergancy of croup?
dexamethasone oral solution
