Respiratory Flashcards
Adult management of asthma
SABA
- Step 1: low dose ICS - preventer therapy
- Step 2: Add LABA - normally as a combination inhaler
- Step 3: Add LTRA - leukotriene receptor antagonist
- Step 4: High dose ICS, add fourth drug; SR theophylline / LTRA
- Step 5: Oral steroid
Examples of LTRA
Montelukast
Zafirlukast
How often should asthma treatment be reviewed?
Every 3 months
What is in a MART?
A single inhaler containing;
- low maintenance ICS
- fast acting LABA
Main side effect of SABA
Hypokalaemia
When to step up SABA
- if using inhaler at least 3 times a week
- night time symptoms
- asthma attack requiring systemic steroids in last 2 years
Main side effect of ICS
Oral thrush
rinse mouth with water after dose
What ICS brands are not interchangeable
Beclomethasone
Qvar and Clenil Modulite
Main side effect of theophylline
Hypokalaemia
Maintain same brand
What are the three parts in step 3 treatment of asthma
- Part 1 (no response): STOP LABA - increase ICS
- Part 2 (inadequate control) : CONTINUE LABA - increase to medium dose ICS
- Part 3 (inadequate control): CONTINUE LABA - trial LTRA, LAMA or SR theophylline
How should oral prednisolone be given?
Single dose in the morning to prevent insomnia
What LABAs are used in asthma
Formoterol - BD
Salmeterol - BD
When wouldn’t LABA be initiated?
Rapidly deteriorating asthma
What LABA can be used as relievers in addition to regular use as preventer in asthma
Formoterol
Inhaler brands containing LABA
And which type
- Fostair - beclomethasone + Formoterol
- Symbicort - Budesonide + Formoterol
- Duoresp spiromax - budesonide + Formoterol
- Seretide - Fluticasone + Salmeterol
Side effects of LABA
- hand tremors, tachycardia, hypERGlycaemia
- hypOKalaemia
- serious cardiovascular events (QT prolongation)
Dose frequency of ICS
exception?
Twice daily
Except Ciclesonide - OD
Mometasone - OD/BD
Age restriction of ICS inhalers
Easyhaler - 18+
QVAR - 12+
Side effects of ICS
Hoarse voice
Sore throat
Oral thrush - use daktarin gel (miconazole)
Paradixical bronchospasm - STOP and give alternative
In mild bronchospasm; use SABA beforehand or transfer from pMDI to dry powder inhaler
What inhaler must be kept refrigerated
Fostair
Side effects of LRA
- Churg Strauss syndrome (vasculitic rash, worsening pulmonary symptoms, cardiac complications)
- Liver toxicity
Target plasma conc of theophylline
10-20 mg/L
take sample after 4-6 hours
Signs of theophylline toxicity
’FAST and SICK
- vomiting and GI effects initially
- tachycardia, CNS stimulation
- arrhythmias, convulsions and hypOKalaemia
Theophylline interactions
- HypOKalaemia - diuretics, corticosteroids, B2 agonists
- Convulsions - Ciprofloxacin, quinolones
- CCB, cimetidine, phenytoin, fluconazole, Macrolides - Enzyme inhibitors
- St John’s Wort, Rifampicin
General inhaler technique
- Breathe out, fully and gently
- Place inhaler mouthpiece in the mouth and seal the lips around the mouthpiece
- Breathe in (pMDIs: slow and steady, DPIs: quick and deep)
- Remove inhaler from the mouth and hold breath for up to 10 seconds
- Wait for a few seconds then repeat as necessary
How is acute asthma treated
Oxygen if required (pO2 94-98%)
Prednisolone 40-50mg OD min 5 days - child under 12 up to 3 days
SABA via nebuliser
if symptoms persist, repeat and add nebulised ipratropium
Treatment pathway of COPD
- SABA or SAMA (salbutamol or ipratropium)
If no asthma features,
2. LABA + LAMA
3. LABA + LAMA + ICS (3 months if impact on quality of life)
If asthma features,
2. LABA + ICS
3. LABA + LAMA + ICS
Acute exacerbation of COPD tx
- nebuliser - SAMA, SABA or theophylline
- IV aminophylline
- Prednisolone 30mg OD 7-14 days
- Antibacterial therapy - amoxicillin, tetracycline or clarithromycin
Tx of asthma in children (<5 years)
- SABA
- Add LTRA
What is the most sedating antihistamine
Promethazine (BD/TDS)
Others,
Chorphenmine
Hydroxyzine
What antihistamine causes QT prolongation
Hydroxyzine
What are the non sedating antihistamines
‘FLAC’
Acrivastine (TDS)
Cetirizine (OD)
Loratidine (OD)
Fexofenadine (OD)
What antihistamines are sold OTC
Promethazine (insomnia, nause)
Diphenhydramine (insomnia)
Buclizine (migraine only)
Dose of adrenaline 1 in 1000
Child under 6: 150 mcg
Child 6-12: 300 mcg
12+ : 500mcg
When should second adrenaline injection be given
5-15 minutes after first injection
Treatment of anaphylaxis
- Adrenaline and oxygen
- Antihistamine
- Corticosteroid
What is used to treat croup
Dexamethasone oral solution
MHRA warning with Hydroxyzine
QT prolongation
Torsade de pointes
Maximum daily dose of Hydroxyzine
100mg
In elderly = 50mg
What is used to treat lung disease in cystic fibrosis
Mucolytics
- Dornase alpha
- Dornase alfa+ hypertonic sodium chloride
or
hypertonic sodium chloride alone.
Inhaler technique; pMDI (evohaler)
• Start to breathe in slowly and steadily and at the same time press the canister.
• keep your mouth closed and hold your breath for 10 seconds or as long as comfortable.
• If second dose is required, wait 30 seconds,
Inhaler technique: accuhaler
- Breathe out gently and slowly and put your lips around moth piece.
- Breathe in quickly and deeply.
- Remove inhaler from your mouth and hold your breath for 10 seconds or as long as comfortable.
Breathe out gently
Inhaler technique: turbohaler
- Twist off cover and uphold upright
- Turn coloured base as far as it goes it will go in one direction and then back again. You should hear a click.
- Repeat once more.
- Twist off top cover
- Check mouthpiece and dose counter
- Hold upright and twist base to the right and to the left until you hear a click.
- Breathe out slowly and gently.
- Hold inhaler horizontally.
- Put your lips around the mouthpiece
- Breathe in quickly and deeply.
- Remove the inhaler from your mouth, hold your breath for 10 seconds or as long as comfortable.
- Breathe out gently
- If second dose is required, repeat the steps
- Twist cover back on when finished.
Inhaler technique; handihaler
1.Press down on the green button to release cap.
2.Check there’s nothing in the mouthpiece.
3.Open the mouthpiece, take a capsule from the blister pack and place inside the inhaler.
4.Close the mouthpiece until you hear a click.
5.Sit or stand up straight
6. Breathe out gently and slowly
7. Hold inhaler horizontally
8. put your lips around the mouthpiece
9, Put your lips around the mouthpiece
10.breathe in quickly and deeply, you should hear a vibrating noise
11.Remove the inhaler from your mouth, hold your breath for 10 seconds or as long as you’re comfortable.
12.Repeat steps again to make sure you empty the capsule.
13.Open the mouthpiece, tip out the empty capsule into bin and close.
Inhaler technique; ellipta
- Slide cover open until you hear a click.
- Check the mouthpiece
- Hold the inhaler horizontally.
- Sit or stand up straight.
- Breath out gently and slowly
- Put your lips around the mouthpiece
- Breathe in quickly and deeply
- Remove the inhaler from your mouth.
- Breathe out gently
- If second dose is required, close cover to reset and repeat
- Close cover when finished.
Warning with montelukast
Suicidal thoughts
