Respiratory Flashcards
What might patients experience when switching from pMDI to a dry powder inhaler?
Lack of sensation in the mouth and throat
Coughing
What is the MHRA warning for pMDIs?
risk of airway obstruction from aspiration of loose objects
How often should spacer devices be changes?
Every 6-12 months
What is the dilution for nebulisers?
Sodium Chloride 0.9%
What are the four indications for nebulisers?
- deliver beta2 agonist or ipratropium bromide to a patient with acute exacerbation of asthma or COPD
- deliver beta2 agonist, corticosteroid or ipratropium bromide on a regular basis to a patient with severe asthma or reversible airways obstruction when patient unable to use other devices
- deliver antibiotic or mucolytic to a patient with cystic fibrosis
- deliver pentamidine isetionate for prophylaxis of pneumocystis pneumonia
What is considered as moderate acute asthma in adults?
- Increasing symptoms
- Peak flow > 50-75% best or predicted
- No features of acute severe asthma
What is considered as severe acute asthma in adults?
One of the following;
- Peak flow 33-50% best or predicted
- RR ≥ 25/min
- HR ≥110/min
- Inability to complete sentences in one breath
What is considered as life-threatening acute asthma in adults?
Any one of the following;
- Peak flow <33% bets or predicted
- SpO2 <92%
- PaO2 <8kPa
- Normal PaCO2 (4.6-6kPa)
- Silent chest
- Cyanosis
- Poor respiratory effort
- Arrhythmia
- Exhaustion
- Altered conscious level
- Hypotensuin
What is considered as moderate acute asthma in children?
- Able to talk in sentences
- SpO2 ≥92%
- Peak flow >50% best or predicted
- HR ≤ 140/min in children between 1-5 years
- HR ≤ 125/min in children ages over 5
- RR ≤ 40/min in children 1-5 years
- RR ≤ 30/min in children over 5 years
What is considered as severe acute asthma in children?
- Cant complete sentences in one breath or too breathless to talk or feed
- SpO2 <92%
- Peak flow 33-50% best or predicted
- HH ≥ 140/min in children aged 1-5 years
- HH ≥ 125/min in children ages over 5 years
- RR > 40/min in children 1-5 years
- RR > 30/min in children ages over 5 years
What is considered as life-threatening acute asthma in children?
Any one of the following;
- SpO2 < 92%
- Peak flow <33% best or predicted
- Silent chest
- Cyanosis
- Poor respiratory effort
- Hypotension
- Exhaustion
- Confusion
What SpO2 level should be maintained?
94-98%
What is the treatment for acute asthma?
Severe/ life-threatening - Refer!!
Moderate:
1st line: high-dose inhaled SABA ASAP (e.g. salbutamol)
- in mild-moderate acute asthma - pMDI inhaler and spacer can be used
- in severe/ life-threatening asthma - oxygen driven nebuliser, if response poor, consider continuous nebulisation
In all cases of acute asthma - pt’s should be prescribed adequate dose of oral prednisolone while continuing usual ICS
- Alternatives: parenteral hydrocortisone or IM methylprednisolone
What is the treatment for acute asthma in children over 2?
- High flow oxygen via tight fitting mask or nose cannula given to all children with life-threatening acute asthma or SpO2 <94% to achieve normal 94-98%
1st line: inhaled SABA ASAP
- mild-moderate - pMDI and spacer
Severe/ life-threatening asthma:
- administration via oxygen driven nebuliser
In all cases:
- prescribe oral dose of prednisolone for 3 days
–> repeat dose in children who vomit or consider IV route in those who cannot retain oral medicatio
–> continue ICS as usual
If a child over 2 is having an episode of acute asthma, when should they seek urgent medical attention?
If symptoms not controlled after 10 puffs of salbutamol via spacer or if symptoms return within 3-4 hours
What can be added to nebulised beta agonists to provide greater bronchodilation?
nebulised ipratropium bromide
What is given as add-on treatment to bronchodilator therapy in patients with severe COPD with chronic bronchitis?
Roflumilast
How do you manage exacerbations of COPD?
Breathlessness: high-dose short-acting inhaled bronchodilator
Withhold LAMA if SAMA given
Short course prednisolone
- consider osteoporosis prophylaxis in those who require frequent oral corticosteroids
How is mild croup treated?
Single dose of corticosteroids e.g. dexamethasone
How do you treat moderate-severe croup?
Single dose oral corticosteroid (dexamethasone or prednisolone) while awaiting hospital admission
If child too unwell to receive oral medication: IM dexamethasone or budesonide by nebulisation
How do you treat severe croup not controlled with corticosteroid treatment?
Nebulised adrenaline/epinephrine solution 1 in 1000 (1mg/ml) - clinical effects should last 1 hour but usually subside 2 hours after administration
What are the side effects of antimuscarinics?
Arrhythmias
Constipation
Cough
Dizziness
Dry mouth
Headache
Nausea
Inhaled antimuscarinics end in ‘ium’
Name some LABA drugs?
Bambuterol hydrochloride
Fomoterol fumarate
Indacaterol
Olodaterol
Salmeterol
What are the cautions for beta2-adrenoceptor agonists, selective?
Arrhythmia
Cardiovascular disease
Diabetes - risk of hyperglycaemia and ketoacidosis, especially with IV use
Hypertension
Hyperthyroidism
Susceptibility to QT prolongation
Hypokalaemia - particular caution in severe asthma and COPD because this effect may potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, diuretics and by hypoxia
Name some SABA drugs?
Salbutamol
Terbutaline
What are the common side effects of inhaled corticosteroids?
Headache
Oral candidiasis
Pneumonia - in patients with COPD
Taste altered
Voice alteration
What is the MHRA warning for inhaled beclometasone?
CFC-free pMDIs (Qvar and Clenil) are not interchangeable
- should be prescriibed by brand
- Qvar and Fostair has extra fine particles and is more potent
What is the MHRA warning for montelukast?
Risk of neuropsychiatric reactions including speech impairment, obsessive-compulsive symptoms
- evaulate risk
What are the signs and symptoms of theophylline overdose?
Vomiting
Agitation
Restlessness
Dilated pupils
Sinus tachycardia
Hyperglycaemia
Hypokalaemia
Severe symptoms:
Haematemesis
Convulsions
Superventricular and ventricular arrhythmia
What is the satisfactory theophylline concentration?
10-20mg/L
Although, lower concentrations may be effective 5-15mg/L
How do you treat acute attacks of hereditary angioedema?
Administer C1-esterase inhibitor, an endogenous complement blocker derived from human plasma
- cinestat alfa
- icatibant
What is used for short and long term prophylaxis of hereditary angioedema?
Tranexamic acid and Danazol
- danazol avoided in children due to androgenic effect
Short-term: started several days before planned procedure and continued for 2-5 days afterwards
What should be offered to patients with cystic fibrosis with evidence of lung disease?
Offer mucolytic
1st line: dornase alfa
2nd line: dornase alfa + hypertonic sodium chloride
OR hypertonic sodium chloride alone
If dornase alfa unsuitable and lung function is rapidly declining and other osmotic drugs not considered appropriate:
- recommend mannitol dry powder for inhalation
What should be offered to cystic fibrosis patients with deteriorating lung function or repeated pulmonary exacerbations?
Long-term treatment with azithromycin at an immunomodulatory dose (usually 500mg three times a week)
2nd line: stop azithromycin and consider oral corticosteroids
What is the treatment for distal intestinal obstruction syndrome in cystic fibrosis patients?
1st line: meglumine amidotrizoate with sodium amidotrizoate
What do you give cystic fibrosis patients with abnormal LFT?
Ursodeoxycholic acid until liver function restored
What can be given to infants under 3 months for nasal decongestion?
Sodium chloride 0.9%
What is the age restriction for OTC cough suppressants containing codeine?
Avoid in children under 12 and children of any age known to be CYP2D6 ultra-rapid metabolisers
Which OTC cough and cold medicines should be avoided in children under 6?
Those that contain:
- brompheniramine, chlorphenamine, diphenhydramine, doxylamine, promethazine or triprolidine (antihistamines)
- dexatromethorphan (cough suppressant)
- guaifenesin or ipecacuanha (expectorants)
- phenylephrine, pseudoephedrine, ephedrine, oxymetazoline or xylometazoline (decongestants
What is the storage requirements for fostair?
Store in fridge until dispensed then can be stored in room temperature
Do not use fostair beyond 3 months or after the expiry date - whichever is sooner
What is the contraindication for Carbocisteine?
Active peptic ulcer
What are the side effects of Carbocisteine?
GI haemorrhage
Skin reactions
Stevens-Johnson syndrome
Vomiting
When do you take theophylline concentratio?
5 days after starting, 4-6 hours after dose
Which antihistamines are sedating?
- Promethazine
- Chlorphenamine
- Hydroxyzine
- Cyproheptadine
- Alimemazine
- Clemastine
Which antihistamines are not sedating?
- Acrivastine (TDS)
- Cetirizine
- Loratadine
- Fexofenadine
How do you treat an overdose of theophyline?
Activated charcoal - even if more than an hour has elapsed after ingestions and especially if it is a MR formulation
Hypokalaemia - IV potassium chloride
Convulsions - IV lorazepam or diazepam
Tachycardia, hypokalaemia,
and hyperglycaemia - IV short acting beta blocker
What is the MHRA warning for hydroxyzine?
Risk of QT prolongation and torsade de pointes
Max. daily dose in children with body-wright up to 40kg = 2mg/kg
Max. daily dose in adults = 100mg
Max. daily dose in elderly = 50mg
What is the adrenaline dose for cardiopulmonary resuscitation?
1 in 10,000 solution IV used for cardiopulmonary resuscitation
- 1mg every 3-5 mins
What is Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) an adverse effect of?
Montelukast
In many of the reported cases the reaction followed the reduction or withdrawal of oral corticosteroid therapy. Prescribers should be alert
to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications,
or peripheral neuropathy.
What conditions increase theophylline concentration?
Heart failure
Hepatic impairment
Viral infections
When should sample of aminophylline be taken?
Sample should be taken 4-6 hours after starting treatment
When would a patient not require a loading dose of aminophylline?
If they already take oral theophylline
Should actual body weight always be used to calculate aminophylline dose?
No - use IBW if patient is obese or in extreme body weights
What is the only route of administration for aminophylline?
IV
Which drug has no drug interactions?
Carbocisteine
Deficiency of what electrolyte is often seen in asthmatic patients?
Deficiency of magnesium
Which prophylactic antibiotic treatment should you consider in patients who are non-smokers and have all other treatments optimised?
Azithromycin
What is the COPD oxygen target?
88-92%
