Respiratory Flashcards
You receive a prescription for beclometasone dipropionate inhalers. What is the issue with this?
The two brands are not interchangeable so should be prescribed by brand or the prescriber contacted. Qvar (and fostair) has extra fine particles so is twice as potent as Clenil.
What dose of Qvar inhaler should be prescribed for a patient moving from 200mcg daily pulmicort?
200 - 250 mcg budesonide for 100mcg of Qvar. So 100mcg daily. (50mcg twice daily)
What is contained in relvar ellipta?
Fluticasone (ICS) and vilanterol (LABA)
What is contained in trelegy ellipta?
Fluticasone, umeclidinium and vilanterol
What corticosteroid containing inhalers and doses are used in COPD?
Fostair 100/6, duoresp spiromax, trimbow, seretide, trelegy ellipta and relvar ellipta 92/22
How are monoclonal antibodies targeted for asthma?
The interfere with interleukin 5 binding which reduces eosinophils and basophils.
What brand contains glycopyrronium and indacaterol?
Ultibro breezhaler
What inhaler contains umeclidinium alone?
Incruse ellipta
Which of these is non sedating: clemastine, mizolastine, hydroxyzine, or ketotifen
Mizolastine
Is fexodenadine sedating or non sedating?
Non sedating
Name the 2 short acting beta agonists
Salbutamol and terbutaline.
What is olodaterol?
Long acting beta agonist
What precautions should be considered with roflumilast treatment?
Monitoring body weight and contraception
What 2 respiratory drugs have a risk of churg strauss and what symptoms does this cause?
Montelukast and omalizumab. Eosinophilia, rash, cardiac complications)
Cromoglicate related drugs should be withdrawn over a month. True or false.
False. Over a week.
In what conditions can theophylline levels be effected and how?
Increased in heart failure, hepatic impairment, viral infections. Decreased with smoking and alcohol
When should aminophylline levels be taken?
4-6 hours after IV or MR. 5 days after oral. 3 days after a change in dose (oral).
What is icatibant used for?
Hereditary angioedema with c1 esterase inhibitor deficiency
When should mucolytics be cautioned?
History of peptic ulceration
What drug and regime is given in paracetamol overdose?
Acetylcysteine. 3 consecutive IV infusions over 21 hours.
What respiratory stimulant is given in respiratory depression/failure?
Doxapram hydrochloride
What age can dry powder devices be used?
Over 5 years (when unable or unwilling to use mdi)
What differences may patients experience when switching from mdi to dpi?
Lack of sensation in mouth and throat. Coughing may occur.
How should spacer devices be cleaned?
Monthly with mild detergent and allowed to dry without rinsing
How often should spacer devices be replaced?
6 to 12 monthly
Why may one type of nebuliser be used as apposed to another?
Droplet size of 1 - 5 is required for airway deposition in asthma but 1 - 2 microns required for alveolar (petamidine for pneumocystis)
Peak flow meters have not been proven to improve control so when may they be used ?
In poor percievers that detect deterioration slower
What is defined as complete control of asthma?
No daytime symptoms, night time wakening, ashma attacks, need for rescue medication, limitations to activity
FEV1 or PEF over 80% minimal side effects
What lifetystle advice is relevant to asthmatics
Weight loss, smoking cessation, breathing exercise programmes
When should patients be urgently assessed with only a beta 2 agonist inhaler?
If using more than one per month
When and how should patients be started on ICS maintenance therapy for asthma?
If using SABA or symptomatic 3 times weekly or more. If waking at night at least once weekly. BTS also advises if asthma attack in last 2 years
Twice daily initially
A patient is taking a SABA and low dose ICS and their asthma is uncontrolled, what may be prescribed next?
LTRA in addition. Review in 4 to 8 weeks (only option in under 5 year olds - refer to specialist if this does not work)
(BTS) LABA
Same as above if child but if 5 - 12yo, LABA or LTRA with BTS.
Then LABA/ICS combination with or without LTRA
What is MART and when may it be introduced?
Maintenance and reliever therapy (ICS and fast acting LABA) . If asthma is uncontrolled on ICS/LABA combination. Used with low dose ICS as maintenance
What further add on options are there if asthma is uncontrolled with SABA, low dose ICS plus one other drug (usually LABA) or MART regimen
Increasing ICS to medium dose
High dose ICS (over 12yo)
LTRA
MR theophylline
LAMA (over 12yo)
An adult patient is uncontrolled on the highest appropriate dose ICS and a LABA. What is the next step?
Oral corticosteroids
Immunosupprrssants, monoclonal antibodies
When suspecting asthma following reliever therapy, 5 year olds are given moderate doses and 5-12 year olds are given low doses, why is this?
The 5 year old dose is an 8 week trial before first line (low dose) maintenence therapy to review diagnosis
When can patients be considered for decreasing therapy?
Once controlled for at least 3 months. Decrease ICS 25 - 50% each time to keep on lowest possible dose
Which drugs are best for exercise induced asthma?
LTRA LABA Oral beta 2 agonist Sodium cromoglicate Nedocromil Theophylline Inhaled SABA should be use immediately before exercise
Which drugs for asthma can be used as normal during pregnancy?
SABA, LABA, oral and ICS, sodium cromoglicate, Nedocromil and oral/IV theophylline
LTRA limited info but don’t withhold
What thresholds determine severity of acute ashma?
Peak flow - >50% moderate, 33 severe, under LT
Respiratory rate - 25 severe (30 if 5y and over, 40 if 2-5yo)
Heart rate - 110 severe (125 if 5y and over, 140 of 2-5y)
SpO2 < 92%, PaO2 <8kpa, silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, hypotension - LT
Raised PaCO2 requiring mechanical ventilation (near fatal)
What is given in acute asthma?
High dose inhaled SABA in spacer or driven by oxygen if life threatening.
Prednisolone oral once daily for at least 5 days or 3 in children (or parentareal HC or IM methylprednisolone)
Maybe combine nebuliser with ipratropium
Magnesium sulfate
Aminophylline (life threatening)
Continuous IV infusion of salbutamol may be option in children over 2y
What vaccines are appropriate in COPD
Pneumococcal polysaccharide and influenza
What inhalers are given in COPD?
If FEV1 above 50% LAMA or LABA. ICS/LABA if still symptomatic
If FEV1 below, LAMA or LABA/ICS
Triple therapy then
What is given in an exacerbation of COPD ?
Nebulisers
Aminophylline
Short course corticosteroid for 7 - 14 days.
Antibacterial
What target oxygen saturations exist?
94 - 98% normally
88 - 92% if risk of hyoercapnic respiratory failure (COPD, CF, TB, overdose on respiratory depressive medication)
What drugs are given in croup?
Corticosteroids. Single dose in mild or before hospital by mouth. Then dexamethasone or budesonide in hospital and every 12 hours if necessary
Nebulised adrenaline
What cautions are there for antimuscarinics and which particular drugs?
Angle closure glaucoma - reported with Nebulised ipratropium especially with salbutamol
Prostatic hyperplasia
Bladder outflow obstruction
What caution may require monitoring with beta 2agonists?
Hypokaleamia. Particularly in severe asthma due to concomitant therapy with theophylline, corticosteroid, diuretics and hypoxia. Plasma concentrations monitored.
What is the duration of action of formoterol and salmeterol?
12 hours
What is the duration of action of salbutamol and terbutaline ?
3 to 5 hours
When should oral corticosteroids be taken?
Morning
What lifestyle choice may effect corticosteroid dosing?
Smoking
How is oral candidiasis risk reduced?
Spacer devices, rinse with water.
Which way round is most suitable for inhaling an ICS and SABA?
SABA then ICS to reduce paradoxical bronchospasm
What monitoring should be done in children taking prolonged treatment of ICS?
Height and weight
Should people taking ICS carry steroid cards?
In high doses
What infection should be treated before starting monoclonal antibodies in asthma?
Helminth
What side effect can occur with asthma treatment that would cause eosinophilia, vasculitic rash, cardiac symptoms or peripheral neuropathy? Which drugs?
Churg strauss syndrome (eosinophilic granulomatosis)
Omalizumab and montelukast/zafirlukast
What conditions may effect plasma theophylline concentrations?
Heart failure, hepatic impairment and viral infection increase
Smokers and alcoholic consumption decreases
What are the symptoms of theophylline toxicity?
Vomiting, agitation, restlessness, dilated pupils, sinus tachycardia, hyperglycemia
Convulsions, ventricular arrythmias
What is the ideal plasma concentration for theophylline and when should levels be taken following IV Aminophylline?
10 - 20mg/l
4-6h after IV
5d after oral, 4-6h after Mr oral dose
Which antihistamines are most sedating? What is the advantage
Alimemazine, promethazine > chlorphenamine, cyclizine
Manages pruritus
Which medicinal products are particularly associated with anaphylaxis?
Blood products, vaccines, allergen preparations, antibacterials, NSAIDs and neuromuscular blocking drugs.
What drugs are given in anaphylaxis and angioedema?
Adrenaline 500mcg (or 300mcg self)
Oxygen/fluids
Antihistamine chlorphenamine
IV corticosteroid hydrocortisone
What effects can antihistamines have in pregnancy?
Sedating can cause irritability, paradoxical excitability and tremor in neonates
When are mucolytics cautioned?
Peptic ulceration history (or active) as may disrupt mucosa barrier.
What drugs is offerdd with cystic fibrosis patients who have evidence of lung disease?
Dornase alfa
Hypertonic sodium chloride
Mannitol dry powder inhaled
What is used to eradicate psuedomonas aeruginosa infections in cf?
Colistimethate sodium Nebulised
What gastrointestinal drugs may be given in cystic fibrosis?
Pancreatin
PPI or h2 antagonists
Ursodeoxycholic acid
What is dextromorphan?
Cough suppressant
Why are antihistamines used in cough medicines?
Suppressant
What are the considerations when deciding between oral or local decongestants?
Local more effective but cause rebound congestion
At what age is it not advised to use strong aromatic decongestants on pillows/as rubs?
Under 3 months
What are the recommendations for OTC cough and cold remedies for under 12 year olds?
Under 6 should not be given antihistamines, cough suppressants, expectorant or decongestant containing products
Can be considered at 6 - 12 year olds but limit to 5 days.
What issues are there with pirfenidone?
Photosensitivity - adjust dose if rash occurs
Reeduce dose with high dose ciprofloxacin
2 week titration will need to be repeated if interruption of more than 14 days occurs
Monitor for weight loss and test liver function
Dizziness or malaise can effect skilled tasks
When are respiratory stimulants use?
Replaced by ventilatory support but may be contraindicated or hyoercapnic respiratory failure
