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BNF Chapters > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What is Cystic Fibrosis

A

A genetic disorder affecting the lungs, pancreas, liver, intestine, and reproductive organs

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2
Q

Signs of Cystic Fibrosis

A

Pulmonary disease, with recurrent infections and the production of copious viscous sputum, and malabsorption due to pancreatic insufficiency.

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3
Q

Complications of CF

A

Hepatobiliary disease, osteoporosis, cystic fibrosis-related diabetes, and distal intestinal obstruction syndrome

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4
Q

Aim of CF treatment

A

Loosening and removing thick, sticky mucus from the lungs, preventing or treating intestinal obstruction, and providing sufficient nutrition and hydration.

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5
Q

Non-drug CF treatment

A

Physiotherapists, airway clearance advice , exercise

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6
Q

Cystic Fibrosis treatment

A

Mucolytics, preventing lung infection, maintaining lung function

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7
Q

Mucolytics choices

A

Dornase alfa first line if inadequate then use in conjunction with hypertonic sodium chloride or just hypertonic sodium chloride alone

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8
Q

What is used in rapidly declining lung function if dornase unsuitable

A

Mannitol dry powder for inhalation

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9
Q

Preventing Staph A

A

Use anti-staph if clinically well and broad-spectrum with activity against staph a if clinically unwell and have pulmonary disease

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10
Q

Treat P Aeruginosa

A

Eradication therapy and course of oral Abx (Iv if clinically unwell) and inhaled antibacterial then extended course of oral and inhaled antibacterial, if unsuccessful treat with nebulised colistimethate sodium

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11
Q

What to use if deteriorating on P Aeriginosa treatment

A

If deteriorating whilst taking inhaled colistimethate sodium can use Nebulised aztreonam, nebulised tobramycin, or tobramycin dry powder for inhalation

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12
Q

What to offer to

patients with deteriorating lung function or repeated pulmonary exacerbations

A

Long-term treatment with azithromycin [unlicensed indication], at an immunomodulatory dose

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13
Q

Why is Pancreatin (creon) given

A

To those with exocrine pancreatic insufficiency

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14
Q

Use of PPI / H2 receptor antagonist in Cystic Fibrosis

A

Considered for those with persistent symptoms/signs of malabsorption

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15
Q

Liver disease and CF

A

If liver function test abnormal then ursodeoxycholic acid given until liver function restored

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16
Q

Distal intestinal obstruction syndrome treatment

A

Oral/IV fluids to ensure adequate hydration, meglumine amidotrizoate also first-line macrogols second line, surgery a last resort

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17
Q

Treating mild croup

A

Largely self limiting but single dose corticosteroid like oral dexamethasone may be useful

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18
Q

More severe croup/mild croup with complications treatment

A

Corticosteroid orally then via nebulisation

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19
Q

Croup is

A

Infection of upper airway

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20
Q

Croup symptoms

A

Characteristic barking cough, swelling around voice box, trachea and bronchi, hoarse voice, difficulty breathing, initially cold like symptoms temperature runny nose, rasping sound breathing in

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21
Q

What OTC meds can you not give for croup

A

Cough or cold medicines

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22
Q

How long does croup last

A

48 hours

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23
Q

When to see GP/refer croup

A

If not better after 48 hours or deterioration or under 3 months

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24
Q

Lifestyle advice for croup

A

Stay calm, sit child upright, give plenty of fluids , do not give cough/cold meds

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25
Q

When to call 999 for croup

A

Child struggling to breathe (you may see their tummy sucking inwards or their breathing sounds different) their skin or lips start to look very pale or blue they’re unusually quiet and still they suddenly get a very high temperature or become very ill

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26
Q

An is analeptic (+example)

A

Doxapram

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27
Q

When are analeptics (respiratory stimulants) used

A

If ventilator support is contra-indicated and in patients with hypercapnic respiratory failure that are becoming drowsy/comatose it may arouse patients to sufficiently cooperate and clear secretions

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28
Q

Who is ambulatory oxygen not recommended for

A

Heart failure, COPD with mild/no hypoxaemia at rest

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29
Q

When is long term oxygen therapy not offered

A

Those who continue to smoke despite being offered cessation interventions

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30
Q

Who is given ambulatory oxygen therapy

A

Those on long term therapy who are often away from home

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31
Q

How often should long term therapy oxygen be reviewed

A

Risk assessment done and reviewed at least annually

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32
Q

Who should long term oxygen therapy be considered in

A

<7.3 and 8 kPa in some instances , stable COPD , heart failure , interstitial lung disease

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33
Q

Why is long term oxygen given

A

Improves survival in COPD and patients with severe hypoxaemia

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34
Q

How long is long term oxygen given for a day

A

At least 15 hours a day

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35
Q

What does oxygen alert card contain

A

Endorsed with the oxygen saturations required during previous exacerbations, should be shown to HCPs

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36
Q

Why is low oxygen concentration given

A

Aim is to provide the patient with enough oxygen to achieve an acceptable arterial oxygen tension without worsening carbon dioxide retention and respiratory acidosis

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37
Q

When is high concentration oxygen therapy safe

A

Pneumonia, pulmonary thromboembolism, pulmonary fibrosis, shock, severe trauma, sepsis, or anaphylaxis, acute severe asthma

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38
Q

Aim of treatment in hypercapnic respiratory failure risk

A

88-92%

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39
Q

Aim of oxygen treatment in those with a normal or low arterial carbon dioxide (PaCO2)

A

Oxygen saturation should be 94–98% oxygen saturation

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40
Q

Oxygen indication

A

Hypoxaemic patients to increase alveolar oxygen tension and decrease breathing work

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41
Q

What respiratory drugs can be given by injection

A

Beta-agonists, corticosteroids, aminophylline

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42
Q

Who is oxygen dangerous for in jet nebulisers

A

Patients at risk of hypercapnia, such as those with chronic obstructive pulmonary disease - drive by air

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43
Q

What to do before a nebuliser is prescribed

A

Home trial to monitor response for up to 2 weeks on standard treatment and up to 2 weeks on nebulised treatment

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44
Q

Side effect of beta agonist when used in a severe asthma attack and overcoming it

A

Increases arterial hypoxaemia so use oxygen but do not delay use to get oxygen

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45
Q

How long are nebulisation solutions administered in severe/ life threatening asthma attacks

A

5-10 mins driven by air

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46
Q

How often should spacers be replaced

A

6-12 mouths

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47
Q

How should spacers be washed

A

Mild detergent, dry in air without rinsing, wipe detergent off mouthpiece before use

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48
Q

How often should spacers be washed

A

Once a month

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49
Q

Spacers mechanism of action

A

Reduces the velocity of the aerosol and subsequent impaction on the oropharynx and allows more time for evaporation of the propellant so that a larger proportion of the particles can be inhaled and deposited in the lungs.

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50
Q

Who are spacers useful for

A

Poor technique, children, high ICS dose, nocturnal asthma, prone to candidiasis

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51
Q

What to do before actuating a pMDI

A

Ensure that mouthpiece removed, shake device,

check outside and inside of mouthpiece and undamaged to avoid inhaling any object/broken pieces

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52
Q

What do patients realise when switching from pMDI to DPI

A

Lack of sensation in the mouth and throat previously associated with each actuation.
Coughing may also occur.

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53
Q

Who are DPIs useful for

A

Adults and children over 5 years who are unwilling or unable to use a pressurised metered-dose inhaler

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54
Q

Benefit of spacers

A

Removes the need to co-ordinate actuation with inhalation

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55
Q

When to consider prednisolone in COPD exacerbations

A

If breathlessness interferes with daily activities on a short course

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56
Q

How to treat COPD exacerbations

A

SABA at higher dose than maintenance through nebuliser/hand held breathlessness device

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57
Q

What to do with LAMA during COPD exacerbation

A

Withhold if SAMA required

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58
Q

Non drug treatment in COPD exacerbations

A

Physiotherapy using positive expiratory pressure devices to help sputum clearance

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59
Q

What do patients who have had an exacerbation in the last year get given

A

Short course of antibacterial, oral corticosteroids

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60
Q

Who requires COPD action plans

A

Those who have had an exacerbation within the last year

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61
Q

Add-on treatment in severe COPD with chronic bronchitis

A

Roflumilast

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62
Q

Can antitussive treatment be used in stable COPD

A

It shouldn’t

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63
Q

When is MR theophylline used in COPD

A

Only after a trial of SABA and LABA or if patient cant used inhaled treatment

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64
Q

What needs to be done before using antibiotics prophylactically for COPD

A

ECG to rule out QT prolongation, LFTs, CT scan of thorax to rule out other lung problems, sputum and sensitivity testing

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65
Q

When to trial LAMA in COPD with no asthmatic features or features suggesting steroid responsiveness

A

If day to day symptoms continue and affect quality of life then trial LAMA

66
Q

When to start triple therapy in COPD patients with asthmatic features or features suggesting steroid responsiveness

A

Those on LABA and ICS with severe exacerbation (needing hospitalisation)/ two moderate exacerbations (needing ICS/Abx) within a year (so you add LAMA to treatment)

67
Q

How long is SABA used for in COPD

A

All stages

68
Q

How often should ICS be reviewed in COPD

A

Annually and document continuation reason

69
Q

When to trial ICS in COPD with no asthmatic features or features suggesting steroid responsiveness

A

If day to day symptoms continue and affect quality of life then trial ICS for 3 months and continue triple therapy if necessary

70
Q

When to start triple therapy in COPD with no asthmatic features

A

Those on LABA and LAMA with severe exacerbation (needing hospitalisation)/ two moderate exacerbations (needing ICS/Abx) within a year (so you add ICS to treatment)

71
Q

COPD step up if no asthmatic features

A

Offer LABA and LAMA discontinue SAMA if LAMA given.

72
Q

What to do before stepping up treatment

A

Confirm diagnosis spirometrically, relevant vaccines given, optimise non drug treatment and confirm use of SABA

73
Q

COPD step up if no asthmatic features

A

Offer LABA and LAMA discontinue SAMA if LAMA given.

74
Q

What to do before a non-asthmatic COPD step up treatment

A

Confirm diagnosis spirometrically, relevant vaccines given, optimise non drug treatment and confirm use of SABA

75
Q

Initial COPD treatment

A

SABA or SAMA

76
Q

When are nebulisers used in COPD

A

Distressing/disabling breathlessness despite maximal use of inhalers

77
Q

Non drug COPD treatment

A

Smoking cessation, pulmonary rehabilitation (physical training, education, nutritional, psychological, behavioural), normal BMI

78
Q

COPD complications

A

Depression, anxiety, type 2 respiratory failure, secondary polycythaemia, cor pulmonale

79
Q

COPD risk factors

A

Tobacco smoking, pollution , genetic, poor lung growth in childhood

80
Q

COPD symptoms

A

Dyspnoea, wheeze, chronic cough, regular sputum production

81
Q

COPD characteristics

A

Persistent respiratory symptoms, airflow limitation, not fully reversible

82
Q

When to inform a GP of an attack

A

Within 24 hours of discharge and the patient should be reviewed by their GP within 2 working days

83
Q

What to do in those who respond poorly to first line acute asthma treatment

A

Magnesium sulfate IV, could consider bolus iv salbutamol, aminophylline in life threatening instances

84
Q

When is PICU needed in asthma

A

Severe asthma despite frequent nebulised beta and ipratropium plus oral corticosteroids

85
Q

Kids and prednisolone

A

Give oral prednisolone for up to 3 days, take repeat dose if child vomits

86
Q

First-line kids acute attack

A

SABA, stop LABA if SABA given on a 4 hourly basis, seek medical attention if symptoms not controlled with 10 puffs of salbutamol via spacer

87
Q

What to do if poor response to SABA in acute attack

A

Ipratropium with a beta agonist, can also add magnesium

88
Q

When to use aminophylline in acute asthma

A

Life-threatening

89
Q

Use of magnesium sulfate and when

A

Bronchodilator effects, if peak flow <50% in paeds it is added

90
Q

What to do if poor response to SABA

A

SAMA, nebulised ipratropium combined with beta agonist

91
Q

Stance or corticosteroids and acute asthma

A

Oral prednisolone for all, use parenteral hydrocortisone/IM methylprednisolone if oral route not possible

92
Q

First-line acute asthma treatment

A

SABA - salbutamol/terbutaline, nebulise if not effective

93
Q

What oxygen should be given to hypoxaemic asthma

A

94-98% SpO2

94
Q

Life-threatening asthma in kids signs

A

SpO2<92
Peak flow <33
Silent chest, cyanosis, hypotension, exhaustion, confusion

95
Q

Life threatening acute asthma signs

A

Peak flow <33%

Arterial o2 saturation <92%

96
Q

Severe acute asthma

A

Peak flow 33-50% best/predicted
Respiratory rate >25/min
Heart rate >110
Inability to complete sentences in one breath

97
Q

Acute asthma symptoms

A

Breathlessness, wheeze, cough, chest tightness

98
Q

Add on therapy in under 5s asthma

A

LRTA in addition to ICS if not refer

99
Q

Children under 5 maintenance therapy

A

Trial moderate paediatric vote

100
Q

Children under 5 reliever

A

SABA

101
Q

What monoclonal antibodies and immunosuppressants are used in asthma

A

Omalizumab, MTX, mepolizumab, benralizumab and reslizumab

102
Q

What children can use oral corticosteroids

A

If already tried high dose, LABA, LRTA, tiotropium (over 12), MR theophylline according to BTS

103
Q

Additional paediatric control

A

Remove LRTA if ineffective and start LABA, if still uncontrolled change to MART regimen if still uncontrolled increase ICS to paediatric moderate dose if not then seek specialist can trial on MR theophylline/ paediatric high dose

BTS 5-12 continue LABA or LRTA and increase dose to low dose or add LRTA/LABA (whichever is not being used) if LABA is not working in 5-12 or >12 then increase ICS to low or medium respectively and discontinue LABA if still not working increase ICS again with spacer or add LRTA if not used or MR theophylline or tiotropium (if>12 yo)

104
Q

Additional paediatric control to combat asthma (NICE)

A

Remove LRTA if ineffective and start LABA, if still uncontrolled change to MART regimen if still uncontrolled increase ICS to paediatric moderate dose if not then seek specialist can trial on MR theophylline/ paediatric high dose

105
Q

Additional paediatric control to combat asthma (BTS)

A

BTS 5-12yo continue LABA or LRTA and increase dose to low dose or add LRTA/LABA (whichever is not being used) if LABA is not working in 5-12 or >12 then increase ICS to low or medium respectively and discontinue LABA if still not working increase ICS again with spacer or add LRTA if not used or MR theophylline or tiotropium (if>12 yo)

106
Q

Initial add on in paeds asthma (NICE)

A

LRTA and review in 4-8 weeks.

107
Q

Initial add on in paeds (BTS)

A

BTS say LABA IN> 12, LABA/LRTA in 5-12, the LABA can be a MART regimen

108
Q

What is used to treat Asthma in children BTS

A

Very low dose in under 12 or low dose in over 12 if SABA use >3 times a week/symptomatic three

109
Q

What is used to treat Asthma ( BTS children )

A

BTS= very low ICS (under 12)/ low ICS>12 for same reasons or asthma attack in last two years (all ICS except ciclesonide recommended to be taken BD initially, OD considered in mild disease/good control)

110
Q

What is used to treat Asthma ( NICE children )

A

Paediatric low dose if using SABA 3 times a week/waking at night/symptomatic three times a week

111
Q

Initial child treatment

A

SABA (<1/month)

112
Q

Pregnancy and asthma

A

Take medication as normal

smoking cessation

113
Q

What to do if asthma and exercise is an issue

A

This is technically a sign of poor control so may have to escalate as normal if not then SABA immediately before exercise

114
Q

How often should ICS reductions be made and what percent

A

Every three months by 25-50%, can’t stop abruptly get it to low dose

115
Q

When to consider reducing asthma therapy

A

Controlled on maintenance for at least three months then monitor regularly

116
Q

When should oral corticosteroids be used

A

BTS says in those under specialist care with severe uncontrolled asthma on high ICS who have tried or are still receiving LABA, LRTA, tiotropium MR, theophylline

117
Q

When are aromatic inhalations used

A

Relief of acute rhinitis/sinusitis

118
Q

What do aromatic inhalations often contain

A

Eucalyptus oil

119
Q

Why are aromatic inhalations used and how

A

Inspiration of warm moist air is comforting in bronchitis

120
Q

What to rule out if a patient presents with cough

A

Identify if underlying disorder, asthma, GORD, ACE inhibitor, smoking, environment

121
Q

When are cough suppressants used

A

No identifiable cause and sleep disturbance

122
Q

Example of cough suppressants

A

Codeine, pholcodeine, dextromothorphan, sedating antihistamines

123
Q

What type of cough remedy is dextromothorphan

A

cough suppressants

124
Q

What are demulcent preparations contain

A

Soothing = syrup/glycerol

125
Q

When are demulcents used

A

Dry irritating cough

126
Q

Examples of demulcent

A

Simple linctus

127
Q

What do expectorants do

A

Promote expulsion of bronchial secretions

128
Q

Expectorants examples

A

Guaifenesin/ipecachuanha

129
Q

Nasal decongestant examples

A

Pseudoephedrine

130
Q

Who should compound preparations not be given to

A

Under 6 years old

131
Q

Who should aromatic inhalations not be used in

A

Not advised for those <3 months

132
Q

What should be used for blocked nose in infants

A

Saline nasal drops (give just before feeds to make feeding easier)

133
Q

Who should cough suppressant be avoided in

A

Children under 6

134
Q

What age can dextromethorphan be used

A

Children over 12

135
Q

What cough drugs can’t be given otc for cough and cold in under 6’s

A

Chlorphenamic, diphenhydramine, promethazine, dextromethorphan , pholcodeine, guaifenasin, pseudoephedrine, ephedrine

136
Q

How long should cough/cold preparation be taken in 6-12yo

A

5 days or less

137
Q

Antihistamine respiratory use

A

Nasal allergies, allergic rhinitis (hayfever), vasomotor rhinitis

138
Q

Other antihistamine uses

A

Urticaria, pruritis, insect bites/stings

139
Q

What antihistamines are used in nausea and vomiting

A

Cinnarizine, cyclizine, promethazine

140
Q

Sedating antihistamines

A

Alimemazine, promethazine most sedating but chlorphenamine and cyclizine have some effects

141
Q

Non-sedating antihistamines

A

acrivastine, bilastine, cetirizine hydrochloride, desloratadine , fexofenadine hydrochloride , levocetirizine hydrochloride ), loratadine and mizolastine

142
Q

Anaphylaxis treatment

A

Adrenaline/epinephrine reverses immediate symptoms, secure airway and restore BP by laying flat and putting in the recovery position, give 500mcg IM or 300mcg if self-administered can repeat at 5-minute intervals depending on BP, Pulse and respiratory function. Oxygen and IV fluids given

143
Q

Role of antihistamine in anaphylaxis

A

Chlorphenamine maleate IV/IM as adjunct after adrenaline

144
Q

Role of corticosteroids in anaphylaxis

A

IV corticosteroid like hydrocortisone given secondary to initial management due to delayed onset it is used to prevent further deterioration

145
Q

Treating continuing respiratory depression

A

Bronchodilators inhaled/IV salbutamol, ipratropium, aminophyline or IV magnesium

146
Q

What to give on discharge after anaphylaxis

A

Oral corticosteroid and antihistamine for up to 3 days

147
Q

Where to give IM adrenaline

A

Middle third of thigh

148
Q

Treating angioedema

A

Treating angioedema

149
Q

Treating hereditary angioedema

A

Not like normal use c1-esterase inhibitor, danazol and tranexamic acid used prophylactically

150
Q

Asthma symptoms

A

Cough, wheeze, chest tightness, and breathlessness

151
Q

Asthma treatment aims

A

No daytime symptoms, no night time awakening, no rescue medication, no exercise limitations, normal lung function (FEV/PEF 80% predicted)

152
Q

Step 1 in asthma treatment

A

SABA( terbutaline, salbutamol) <1 a month

153
Q

When to start low dose ICS maintenance

A

Using SABA 3 times a week, waking at night once a week, symptoms three times a week, BTS also says if asthma attack in last 2 years

154
Q

BTS recommendation for low ICS regimen

A

BD but can be OD if mild disease or complete control

155
Q

Initial add on for Asthma (NICE/BTS)

A

Nice say LRTA, BTS say LABA and can use MART

156
Q

When should leukotriene be evaluated

A

4 to 8 weeks

157
Q

What is MART

A

Maintenance And Reliever Therapy—a combination of an ICS and a fast-acting LABA such as formoterol in a single inhaler

158
Q

When to give initial add on

A

If asthma is uncontrolled on a low-dose of ICS as maintenance therapy

159
Q

When to give initial add on

A

If asthma is uncontrolled on a low-dose of ICS as maintenance therapy

160
Q

Additional add on NICE

A

LABA with/without LRTA if still uncontrolled use MART if still uncontrolled increase ICS to moderate if still uncontrolled increase to high ICS/trial LAMA or theophylline

161
Q

Additional add on BTS

A

If LABA gives some benefit but still uncontrolled continue it if not remove and increase ICS to medium if not already / LRTA added, always refer to specialist , can be increased to high ICS or add LRTA if not tried/ MR theophylline/ tiotropium

162
Q

Additional add on BTS

A

If LABA gives some benefit but still uncontrolled continue it if not remove and increase ICS to medium if not already / LRTA added, always refer to specialist , can be increased to high ICS or add LRTA if not tried/ MR theophylline/ tiotropium

BNF Chapters (11 decks)

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