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BNF Topics > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Name the 2 types of obstructive airway conditions.

A
  • Asthma

- COPD

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2
Q

Does asthma cause reversible or irreversible airways obstruction?

A

Reversible.

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3
Q

Symptoms of asthma.

A
  • Coughing (especially at night)
  • SOB
  • Chest tightness
  • Wheezing
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4
Q

What guideline is the ‘gold standard’ of asthma treatment?

A

BTS / SIGN Guidelines.

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5
Q

Outline the BTS Chronic Asthma Guideline (Adults).

A
  • Step 1 - Regular preventer. Low-dose ICS.
  • Step 2 - Initial add-on therapy. Add LABA to low-dose ICS (combination inhaler).
  • Step 3 - Additional add-on therapies. Depending on previous response:
  • No response to LABA - stop LABA and consider an increased dose of ICS.
  • Benefit from Laba but inadequate control - continue LABA and increase ICS to medium dose OR continue LABA+ICS and consider a trial of other therapy, e.g. LTRA, SR theophylline or LAMA.
  • Step 4 - High-dose therapies. Consider trialling: high-dose ICS or adding a 4th drug (SR theophylline / LTRA / LAMA / beta-agonist tablet). Patients should be referred for specialist care from here onwards.
  • Step 5 - Continuous or frequent use of oral steroids. Maintain high-dose ICS. Consider using other treatments to minimise steroid use.
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6
Q

What is considered high-dose ICS (Adults)?

A

Beclometasone - 800-2000mcg

Budesonide - 1600mcg

Fluticasone - 1000mcg

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7
Q

What is considered low-dose ICS (Adults)?

A

Daily drug doses:
Beclometasone - 100-400mcg

Budesonide - 400mcg

Fluticasone - 200-400mcg

Mometasone - 400mcg

Ciclesonide - 160mcg

Daily dose should be in divided doses (BD) then reduced to OD if there’s good control.

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8
Q

How often should adults with chronic asthma be reviewed?

A

Every 3 months.

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9
Q

How should ICS doses be stepped down?

A

Reduce ICS by 25-50% every 3 months until the lowest effective dose.

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10
Q

What should be prescribed at all steps of chronic asthma management?

A

A reliever inhaler:

Usually a SABA (salbutamol / terbutaline).

Alternatives to SABA’s include SAMA’s (ipratropium). If the patient is aged>12, theophylline or oral beta agonist (bambuterol) can be used.

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11
Q

When should chronic asthma management be ‘stepped up’?

A

If:

  • Using reliever inhaler, or patient is symptomatic, at least 3x per week.
  • Night-time symptoms at least OW.
  • Asthma attack requiring systemic steroids in last 2 years.

Patients using >1 reliever inhaler per month should be referred.

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12
Q

What are LABA’s? Give examples for asthma.

A

LABA = long-acting beta agonist

Examples include:

  • Formoterol
  • Salmeterol
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13
Q

What are LAMA’s? Give examples for asthma.

A

LAMA = long-acting muscarinic antagonist

Examples include:
- Tiotropium

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14
Q

What are LTRA’s? Give examples for asthma.

A

LTRA = leukotriene receptor antagonists

Examples include:

  • Montelukast
  • Zafirlukast
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15
Q

How should oral prednisolone be prescribed and given for asthma treatment?

A

Single dose in the morning (prevents insomnia).

Dose should gradually be withdrawn when stepping down treatment (prevents an adrenal crisis).

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16
Q

Outline the BTS Chronic Asthma Guideline (Paediatrics).

A
  • Step 1 - Regular preventer. Very low-dose (paediatric) ICS. If age <5, LTRA.
  • Step 2 - Initial add-on therapy. Very low-dose (paediatric) ICS + either:
  • Age>5 = add LABA.
  • Age<5 = add LTRA.
  • Step 3 - Additional add on therapies. Depending on previous response:
  • No response to LABA - stop LABA and increase dose of ICS to low-dose.
  • Benefit from LABA but inadequate control - continue LABA and increase ICS to low dose OR continue LABA+ICS and consider a trial of LTRA.
  • Step 4 - High-dose therapies. Consider trials of: medium-dose ICS or adding a 4th drug (SR theophylline). Patients from this step onwards should be referred to a specialist.
  • Step 5 - Continuous or frequent use of oral steroids. Maintain medium-dose ICS. Consider other treatments to minimise use of steroids.
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17
Q

What do NICE recommend paediatric patients to use with inhaler devices?

A

For patients using a pMDI, a spacer with face mask should be used if patient is aged <5.

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18
Q

How do selective beta-2 agonists work?

A

Cause bronchodilation of the bronchi.

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19
Q

Duration of action of selective beta-2 agonists.

A

SABA’s - 3-5 hours
- Given QDS PRN.

LABA’s - 12 hours.
- Given BD.

Bambuterol (pro-drug of terbutaline) - 24 hours.

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20
Q

When should LABA’s NOT be initiated?

A

In rapidly deteriorating asthma.

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21
Q

What is the difference between salmeterol and formoterol?

A

Salmeterol = Long-onset + long-action

Formoterol = Short-onset + Long-action.
Due to this, formoterol can be used as relievers in addition to use as a preventer (although use should be reviewed if using more than OD as reliever).

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22
Q

Brands of ICS+LABA combination inhalers.

A

Fostair
DuoResp
Spiromax
Symbicort (+18 years)

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23
Q

Side-effects of selective beta-2 agonists.

A
  • Hand tremors
  • Tachycardia
  • Hyperglycaemia
  • Hypokalaemia - potentiated by corticosteroid use, other B2 agonists and theophylline.
  • Serious CV effects - prolonged QT-interval, arrhythmias, arterial hypoxia (causing MI and hypotension). Caution in hyperthyroidism.
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24
Q

What should prescriptions for selective beta-2 agonists specify?

A

Doses must explicitly state dose, frequency and max puffs/24 hours.

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25
Q

How do inhaled corticosteroids work?

A

Reduce inflammation in the bronchi.

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26
Q

How often are ICS taken?

A

BD: Beclometasone, Budesonide, Fluticasone & Mometasone (can also be OD).

OD: Ciclesonide.

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27
Q

How long must ICS be taken for to be effective?

A

Regular for 3-4 weeks for asthma prevention.

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28
Q

Why should beclometasone be prescribed by brand name?

A

Qvar is 2x more potent than Clenil as it has extra fine particles.

Fostair (beclometasone + formoterol) also has extra fine particles and is more potent than other beclometasone inhalers.

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29
Q

Side-effects of ICS.

A
  • Hoarse/sore throat
  • Oral candidiasis - patients should be counselled on rinsing the mouth and brushing teeth after using, or use a spacer device.
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30
Q

When do NICE recommend a large-volume spacer device to be used?

A
  • High-dose ICS

- Patients aged <15

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31
Q

What is paradoxical bronchospasm?

A

A rare ADR to SABA’s.

It causes the unexpected constriction of smooth muscle walls of the bronchi that occurs when you expect a bronchodilatory response.

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32
Q

True or False - Current and previous smoking reduces efficacy of ICS.

A

True - the patient may require a higher dose than usual.

33
Q

How do LTRA’s work?

A

Blocks action of leukotriene on the cysteinyl leukotriene receptor in the lungs and bronchi; reduces bronchoconstriction and inflammation.

34
Q

Side-effects of LTRA’s.

A
  • Churg Strauss Syndrome - occurs on withdrawal or reduction of oral corticosteroids. Will present as eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications and peripheral neuropathy.
  • Liver toxicity reported with Zafirlukast. Patients should report signs of liver toxicity (N&V, jaundice, abdominal pain, itching etc.).
35
Q

What is the target therapeutic range of theophylline?

A

10-20mg/L (55-110 mmol/L).

36
Q

When should theophylline blood samples be taken?

A

4-6 hours after dose is given.

37
Q

When will plasma theophylline concentration be increased?

A
  • HF
  • Hepatic impairment
  • Viral infections
  • Elderly
  • Taken in conjunction with enzyme inhibitors
38
Q

When will plasma theophylline concentration be decreased?

A
  • Smokers
  • Alcohol
  • Concomitant use of enzyme inducers
39
Q

True or False - Theophylline should be prescribed by brand.

A

True - brands are not bioequivalent.

40
Q

What are the signs of theophylline toxicity?

A

FAST & SICK:

  • Vomiting and GI side-effects initially
  • Tachycardia, CNS stimulation
  • Arrhythmias, convulsions and hypOkalaemia.
41
Q

Theophylline interactions.

A

Increased risk of hypOkalaemia:

  • Loop/thiazide-like diuretics
  • Corticosteroids
  • Beta-2 agonists

Increased risk of convulsions:
- Ciprofloxacin (quinolones are enzyme inhibitors and lower seizure threshold).

Increased plasma concentration and risk of toxicity:
- Verapamil / calcium channel blockers
- Cimetidine
- Phenytoin
- Fluconazole
- Macrolides
All are enzyme inhibitors.

Reduced plasma concentration (subtherapeutic):
- St. John’s Wort
- Rifampicin
All are enzyme inducers.

42
Q

What is the initial treatment for acute asthma?

A

Salbutamol - 2-10 puffs every 10-20 minutes / PRN

Alternatively

Salbutamol / Terbutaline nebuliser (oxygen driven where possible) every 20-30 minutes / PRN

Symptoms persisting after 15-30 minutes require emergency services. The above should be repeated and nebulised ipratropium bromide added.

43
Q

What should be given in all cases of acute asthma?

A

Prednisolone (PO) / Hydrocortisone (IV)

  • Aged<12 = up to 3 days
  • Aged >12 - at least 5 days (40-50mg OD)
44
Q

Does COPD cause reversible or irreversible airways obstruction?

A

Irreversible.

45
Q

What happens to the lungs in COPD?

A

The bronchioles lose their shape and become clogged with mucus. The walls of the alveoli are destroyed forming fewer larger alveoli.

46
Q

How is the severity of COPD assessed?

A

Spirometry.

FEV1 (Forced expiratory volume) measures the amount of air the lungs can force out in 1 second. The lower the FEV1, the more severe the COPD.

47
Q

Outline the COPD treatment pathway.

A

Initial breathlessness or exercise limitation:
- SABA / SAMA. These are continued throughout treatment (SAMA’s must be stopped if a LAMA is started).

Exacerbation or persistent breathlessness:

  • FEV > 50% = LABA (then LABA+ICS) / LAMA.
  • FEV < 50% = LABA+ICS / LAMA.

Persistent exacerbation or breathlessness:
- Triple therapy with LABA+ICS+LAMA

Persistent symptoms or unable to use the inhaler:
- MR theophylline

Chronic productive cough:
- Mucolytic (carbocisteine)

Severe COPD with hypoxemia:
- Oxygen therapy (15 hours daily+ prolongs survival).

48
Q

What is the target oxygen saturation for COPD patients?

A

88-92%.

49
Q

How to inhaled antimuscarinics work?

A

Relaxes smooth muscle of the bronchi to cause bronchodilation.

50
Q

What LABA’s are used in COPD?

A
  • Formoterol (Fostair)
  • Salmeterol
  • Olodaterol (Striverdi Respimat)
  • Indaceterol (Onbrex Breezhaler)
  • Vilanterol w/ umeclidinium (Anoro Elipta)
51
Q

What LAMA’s are used in COPD?

A
  • Aclidinium (Elikra Genuair)
  • Glycopyronnium (Seebri Breezhaler)
  • Umeclidinium (Incruse Elipta)
  • Tiotropium (Spiriva Handihaler)
    All LAMA’s are taken OD (except Elikra - BD).

LABA / LAMA combination inhalers are available.

52
Q

Antimuscarinic cautions and side-effects.

A

Cautions:

  • Prostatic hyperplasia.
  • Risk of angle-closure glaucoma.

Side-effects:

  • Dry mouth.
  • Paradoxical bronchospasm.
53
Q

How are acute COPD exacerbations managed?

A
  • Bronchodilator therapy.
  • IV aminophylline (if poor response to bronchodilator).
  • Short course of oral prednisolone (30mg OD for 7-14 days - increased if breathlessness interferes with daily activities).
  • Antibiotic therapy - if purulent sputum or other signs of infection present.
54
Q

How do antihistamines work?

A

Bind to H1 receptors blocking the action of histamine.

55
Q

What are the old sedating antihistamines?

A
  • Promethazine (Most sedating - given BD/TDS)
  • Alimemazine (Most sedating)
  • Chlorphenamine (given QDS)
  • Hydroxyzine (QT prolongation)
  • Ketotifen
  • Clemastine
  • Cyproheptadine
56
Q

What are the new less-sedating antihistamines?

A
  • Acrivastine (TDS)
  • Bilastine
  • Mizolastine
  • Cetirizine / Levocetirizine (OD)
  • Loratidine / Desloratidine (OD)
  • Fexofenadine (OD)
57
Q

What are antihistamines used for?

A

Mainly allergies, e.g. hay fever and urticaria.

Other uses include:

  • N&V - cinnarizine, cyclizine, promethazine, buclizine (with migraine preparations)
  • Insomnia - promethazine, diphenhydramine
  • Adjunct in emergency anaphylaxis and angioedema - chlorphenamine / promethazine inection.
58
Q

Cautions with antihistamine use.

A
  • BPH (urinary retention)
  • Glaucoma (raised IOP)
  • Severe liver impairment (sedation precipitates hepatic coma)
59
Q

What are the risks surrounding hydroxyzine use?

A

QT-prolongation and Torsade de pointes.

Should only be used for a short-period only; max. adult daily dose = 100mg.

CI (risk factors for QT prolongation):

  • Concomitant drugs increasing QT interval
  • CVD
  • Family Hx of sudden death
  • HypOkalaemia
  • HypOmagnesaemia
  • Bradycardia
60
Q

When is allergy immunotherapy used?

A
  • To reduce allergic asthma symptoms or allergic rhinoconjunctivitis.
  • To reduce severe anaphylaxis in hypersensitivity to wasp and bee stings.

Desensitising vaccines can be used for hayfever unresponsive to other anti-allergy drugs, and for hypersensitivity to wasp and bee venom. Specialist use only (with monitoring for 1-hour post-dose) with CPR available immediately.

61
Q

When should allergy immunotherapy be avoided?

A
  • Asthma (or use with caution)
  • Pregnant women
  • Children aged < 5
  • Concomitant use with beta-blockers or ACE-i
62
Q

What is omalizumab?

A

A mAb that binds to IgE used in:

  • Severe, persistent allergic asthma (inadequate response to high-dose ICS+LABA requiring frequent oral steroid >4 courses in last year).
  • Chronic spontaneous urticaria in patients aged >12 years (inadequate response to H1 antihistamines and LTRA’s).
63
Q

Omalizumab side-effects.

A
  • Churg-Strauss syndrome

- Hypersensitivity

64
Q

How is anaphylaxis managed?

A
  1. Secure airways and restore BP (raise legs and lay flat - if unconscious or sick, place in recovery position).
  2. Give adrenaline IM injection to mid-thigh repeated every 5 minutes as necessary:
    - Aged <6 = 150mcg
    - Aged 6-12 = 300mcg
    - Aged >12 = 500mcg
    If patient uses beta-blockers, they may not respond to adrenaline - consider using a bronchodilator, e.g. salbutamol.

Adjuncts:

  • High-flow oxygen and fluids
  • Chlorphenamine injection
  • Hydrocortisone injection
65
Q

Management of patients with self-administered adrenaline.

A

Adult = 300/500mcg
Child 15-30kg = 150mcg

Patients should carry 2 auto-injectors at all times and administer to the midpoint of outer thigh. An ambulance should be called even if symptoms improve.

66
Q

What is angioedema?

A

Swelling of the skin caused by allergic reactions.

Should be treated as for anaphylaxis if laryngeal oedema is present.

67
Q

How do mucolytics work? Give examples used in COPD.

A

Facilitate expectoration by reducing sputum viscosity.

Examples include:

  • Carbocisteine
  • Erdosteine
68
Q

When are mucolytics CI? Why?

A

Active peptic ulcers - mucolytics disrupt gastric mucosa.

69
Q

What is croup?

A

A common childhood condition characterised by a barking cough (sounds like a seal), a hoarse voice, difficulty breathing and a rasping sound when breathing in. Children generally have cold-like symptoms with the croup symptoms developing after a few days, generally worsening at night.

70
Q

How is croup managed?

A

Dexamethasone oral solution:
Dose = 150mcg/kg for 1 dose for mild croup, repeated doses used in severe cases, or in mild croup with risk of complications.

71
Q

What medication is used as a respiratory stimulant for respiratory depression?

A

Doxapram.

72
Q

What organs does cystic fibrosis affect?

A
  • Lungs
  • Pancreas
  • Liver
  • Intestine
  • Reproductive organs
73
Q

What are the main clinical signs of cystic fibrosis?

A
  • Pulmonary disease with recurrent infections
  • Production of copious viscous sputum
  • Malabsorption due to pancreatic insufficiency
74
Q

What are the complications of cystic fibrosis?

A
  • Hepatobiliary disease
  • Osteoporosis
  • CF-related diabetes
  • Distal intestinal obstruction syndrome
75
Q

What is the aim of CF treatment?

A
  • Preventing and managing lung infections
  • Loosen and remove mucus from lungs
  • Prevent and treat intestinal obstruction
  • Provide sufficient nutrition and hydration

Optimising lung function is a major aim of care as it’s a predictor of life expectancy.

76
Q

How often should CF patients be reviewed?

A

Frequency of review should be based on clinical condition but at least:

  • Children - every 8 weeks. More frequent review required immediately after diagnosis and during early life.
  • Adults - every 3 months.
77
Q

How is CF managed with mucolytics?

A

1st-Line: Dornase alfa.
2nd-Line: Dornase alfa + hypertonic sodium chloride / hypertonic sodium chloride alone.

Mannitol can be used if dornase alfa is unsuitable, when lung function is rapidly deteriorating or if other osmotic drugs are inappropriate.

Lumacaftor with ivacaftor (Orkambi) is not recommended for CF within its marketing authorisation.

78
Q

When is pancreatin given to CF patients?

A

If they have exocrine pancreatic insufficiency. Dose is adjusted according to symptoms and signs of malabsorption.

79
Q

What can be given to CF patients with abnormal LFTs to restore liver function?

A

Ursodeoxycholic acid.

BNF Topics (11 decks)

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