Respiratory Flashcards
What is Cystic Fibrosis
A genetic disorder affecting the lungs, pancreas, liver, intestine, and reproductive organs
Signs of Cystic Fibrosis
Pulmonary disease, with recurrent infections and the production of copious viscous sputum, and malabsorption due to pancreatic insufficiency.
Complications of CF
Hepatobiliary disease, osteoporosis, cystic fibrosis-related diabetes, and distal intestinal obstruction syndrome
Aim of CF treatment
Loosening and removing thick, sticky mucus from the lungs, preventing or treating intestinal obstruction, and providing sufficient nutrition and hydration.
Non-drug CF treatment
Physiotherapists, airway clearance advice , exercise
Cystic Fibrosis treatment
Mucolytics, preventing lung infection, maintaining lung function
Mucolytics choices
Dornase alfa first line if inadequate then use in conjunction with hypertonic sodium chloride or just hypertonic sodium chloride alone
What is used in rapidly declining lung function if dornase unsuitable
Mannitol dry powder for inhalation
Preventing Staph A
Use anti-staph if clinically well and broad-spectrum with activity against staph a if clinically unwell and have pulmonary disease
Treat P Aeruginosa
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
What to use if deteriorating on P Aeriginosa treatment
If deteriorating whilst taking inhaled colistimethate sodium can use Nebulised aztreonam, nebulised tobramycin, or tobramycin dry powder for inhalation
What to offer to
patients with deteriorating lung function or repeated pulmonary exacerbations
Long-term treatment with azithromycin [unlicensed indication], at an immunomodulatory dose
Why is Pancreatin (creon) given
To those with exocrine pancreatic insufficiency
Use of PPI / H2 receptor antagonist in Cystic Fibrosis
Considered for those with persistent symptoms/signs of malabsorption
Liver disease and CF
If liver function test abnormal then ursodeoxycholic acid given until liver function restored
Distal intestinal obstruction syndrome treatment
Oral/IV fluids to ensure adequate hydration, meglumine amidotrizoate also first-line macrogols second line, surgery a last resort
Treating mild croup
Largely self limiting but single dose corticosteroid like oral dexamethasone may be useful
More severe croup/mild croup with complications treatment
Corticosteroid orally then via nebulisation
Croup is
Infection of upper airway
Croup symptoms
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
What OTC meds can you not give for croup
Cough or cold medicines
How long does croup last
48 hours
When to see GP/refer croup
If not better after 48 hours or deterioration or under 3 months
Lifestyle advice for croup
Stay calm, sit child upright, give plenty of fluids , do not give cough/cold meds
When to call 999 for croup
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
An is analeptic (+example)
Doxapram
When are analeptics (respiratory stimulants) used
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
Who is ambulatory oxygen not recommended for
Heart failure, COPD with mild/no hypoxaemia at rest
When is long term oxygen therapy not offered
Those who continue to smoke despite being offered cessation interventions
Who is given ambulatory oxygen therapy
Those on long term therapy who are often away from home
How often should long term therapy oxygen be reviewed
Risk assessment done and reviewed at least annually
Who should long term oxygen therapy be considered in
<7.3 and 8 kPa in some instances , stable COPD , heart failure , interstitial lung disease
Why is long term oxygen given
Improves survival in COPD and patients with severe hypoxaemia
How long is long term oxygen given for a day
At least 15 hours a day
What does oxygen alert card contain
Endorsed with the oxygen saturations required during previous exacerbations, should be shown to HCPs
Why is low oxygen concentration given
Aim is to provide the patient with enough oxygen to achieve an acceptable arterial oxygen tension without worsening carbon dioxide retention and respiratory acidosis
When is high concentration oxygen therapy safe
Pneumonia, pulmonary thromboembolism, pulmonary fibrosis, shock, severe trauma, sepsis, or anaphylaxis, acute severe asthma
Aim of treatment in hypercapnic respiratory failure risk
88-92%
Aim of oxygen treatment in those with a normal or low arterial carbon dioxide (PaCO2)
Oxygen saturation should be 94–98% oxygen saturation
Oxygen indication
Hypoxaemic patients to increase alveolar oxygen tension and decrease breathing work
What respiratory drugs can be given by injection
Beta-agonists, corticosteroids, aminophylline
Who is oxygen dangerous for in jet nebulisers
Patients at risk of hypercapnia, such as those with chronic obstructive pulmonary disease - drive by air
What to do before a nebuliser is prescribed
Home trial to monitor response for up to 2 weeks on standard treatment and up to 2 weeks on nebulised treatment
Side effect of beta agonist when used in a severe asthma attack and overcoming it
Increases arterial hypoxaemia so use oxygen but do not delay use to get oxygen
How long are nebulisation solutions administered in severe/ life threatening asthma attacks
5-10 mins driven by air
How often should spacers be replaced
6-12 mouths
How should spacers be washed
Mild detergent, dry in air without rinsing, wipe detergent off mouthpiece before use
How often should spacers be washed
Once a month
Spacers mechanism of action
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.
Who are spacers useful for
Poor technique, children, high ICS dose, nocturnal asthma, prone to candidiasis
What to do before actuating a pMDI
Ensure that mouthpiece removed, shake device,
check outside and inside of mouthpiece and undamaged to avoid inhaling any object/broken pieces
What do patients realise when switching from pMDI to DPI
Lack of sensation in the mouth and throat previously associated with each actuation.
Coughing may also occur.
Who are DPIs useful for
Adults and children over 5 years who are unwilling or unable to use a pressurised metered-dose inhaler
Benefit of spacers
Removes the need to co-ordinate actuation with inhalation
When to consider prednisolone in COPD exacerbations
If breathlessness interferes with daily activities on a short course
How to treat COPD exacerbations
SABA at higher dose than maintenance through nebuliser/hand held breathlessness device
What to do with LAMA during COPD exacerbation
Withhold if SAMA required
Non drug treatment in COPD exacerbations
Physiotherapy using positive expiratory pressure devices to help sputum clearance
What do patients who have had an exacerbation in the last year get given
Short course of antibacterial, oral corticosteroids
Who requires COPD action plans
Those who have had an exacerbation within the last year
Add-on treatment in severe COPD with chronic bronchitis
Roflumilast
Can antitussive treatment be used in stable COPD
It shouldn’t
When is MR theophylline used in COPD
Only after a trial of SABA and LABA or if patient cant used inhaled treatment
What needs to be done before using antibiotics prophylactically for COPD
ECG to rule out QT prolongation, LFTs, CT scan of thorax to rule out other lung problems, sputum and sensitivity testing
When to trial LAMA in COPD with no asthmatic features or features suggesting steroid responsiveness
If day to day symptoms continue and affect quality of life then trial LAMA
When to start triple therapy in COPD patients with asthmatic features or features suggesting steroid responsiveness
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)
How long is SABA used for in COPD
All stages
How often should ICS be reviewed in COPD
Annually and document continuation reason
When to trial ICS in COPD with no asthmatic features or features suggesting steroid responsiveness
If day to day symptoms continue and affect quality of life then trial ICS for 3 months and continue triple therapy if necessary
When to start triple therapy in COPD with no asthmatic features
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)
COPD step up if no asthmatic features
Offer LABA and LAMA discontinue SAMA if LAMA given.
What to do before stepping up treatment
Confirm diagnosis spirometrically, relevant vaccines given, optimise non drug treatment and confirm use of SABA
COPD step up if no asthmatic features
Offer LABA and LAMA discontinue SAMA if LAMA given.
What to do before a non-asthmatic COPD step up treatment
Confirm diagnosis spirometrically, relevant vaccines given, optimise non drug treatment and confirm use of SABA
Initial COPD treatment
SABA or SAMA
When are nebulisers used in COPD
Distressing/disabling breathlessness despite maximal use of inhalers
Non drug COPD treatment
Smoking cessation, pulmonary rehabilitation (physical training, education, nutritional, psychological, behavioural), normal BMI
COPD complications
Depression, anxiety, type 2 respiratory failure, secondary polycythaemia, cor pulmonale
COPD risk factors
Tobacco smoking, pollution , genetic, poor lung growth in childhood
COPD symptoms
Dyspnoea, wheeze, chronic cough, regular sputum production
COPD characteristics
Persistent respiratory symptoms, airflow limitation, not fully reversible
When to inform a GP of an attack
Within 24 hours of discharge and the patient should be reviewed by their GP within 2 working days
What to do in those who respond poorly to first line acute asthma treatment
Magnesium sulfate IV, could consider bolus iv salbutamol, aminophylline in life threatening instances
When is PICU needed in asthma
Severe asthma despite frequent nebulised beta and ipratropium plus oral corticosteroids
Kids and prednisolone
Give oral prednisolone for up to 3 days, take repeat dose if child vomits
First-line kids acute attack
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
What to do if poor response to SABA in acute attack
Ipratropium with a beta agonist, can also add magnesium
When to use aminophylline in acute asthma
Life-threatening
Use of magnesium sulfate and when
Bronchodilator effects, if peak flow <50% in paeds it is added
What to do if poor response to SABA
SAMA, nebulised ipratropium combined with beta agonist
Stance or corticosteroids and acute asthma
Oral prednisolone for all, use parenteral hydrocortisone/IM methylprednisolone if oral route not possible
First-line acute asthma treatment
SABA - salbutamol/terbutaline, nebulise if not effective
What oxygen should be given to hypoxaemic asthma
94-98% SpO2
Life-threatening asthma in kids signs
SpO2<92
Peak flow <33
Silent chest, cyanosis, hypotension, exhaustion, confusion
Life threatening acute asthma signs
Peak flow <33%
Arterial o2 saturation <92%
Severe acute asthma
Peak flow 33-50% best/predicted
Respiratory rate >25/min
Heart rate >110
Inability to complete sentences in one breath
Acute asthma symptoms
Breathlessness, wheeze, cough, chest tightness
Add on therapy in under 5s asthma
LRTA in addition to ICS if not refer
Children under 5 maintenance therapy
Trial moderate paediatric vote
Children under 5 reliever
SABA
What monoclonal antibodies and immunosuppressants are used in asthma
Omalizumab, MTX, mepolizumab, benralizumab and reslizumab
What children can use oral corticosteroids
If already tried high dose, LABA, LRTA, tiotropium (over 12), MR theophylline according to BTS
Additional paediatric control
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)
Additional paediatric control to combat asthma (NICE)
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
Additional paediatric control to combat asthma (BTS)
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)
Initial add on in paeds asthma (NICE)
LRTA and review in 4-8 weeks.
Initial add on in paeds (BTS)
BTS say LABA IN> 12, LABA/LRTA in 5-12, the LABA can be a MART regimen
What is used to treat Asthma in children BTS
Very low dose in under 12 or low dose in over 12 if SABA use >3 times a week/symptomatic three
What is used to treat Asthma ( BTS children )
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)
What is used to treat Asthma ( NICE children )
Paediatric low dose if using SABA 3 times a week/waking at night/symptomatic three times a week
Initial child treatment
SABA (<1/month)
Pregnancy and asthma
Take medication as normal
smoking cessation
What to do if asthma and exercise is an issue
This is technically a sign of poor control so may have to escalate as normal if not then SABA immediately before exercise
How often should ICS reductions be made and what percent
Every three months by 25-50%, can’t stop abruptly get it to low dose
When to consider reducing asthma therapy
Controlled on maintenance for at least three months then monitor regularly
When should oral corticosteroids be used
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
When are aromatic inhalations used
Relief of acute rhinitis/sinusitis
What do aromatic inhalations often contain
Eucalyptus oil
Why are aromatic inhalations used and how
Inspiration of warm moist air is comforting in bronchitis
What to rule out if a patient presents with cough
Identify if underlying disorder, asthma, GORD, ACE inhibitor, smoking, environment
When are cough suppressants used
No identifiable cause and sleep disturbance
Example of cough suppressants
Codeine, pholcodeine, dextromothorphan, sedating antihistamines
What type of cough remedy is dextromothorphan
cough suppressants
What are demulcent preparations contain
Soothing = syrup/glycerol
When are demulcents used
Dry irritating cough
Examples of demulcent
Simple linctus
What do expectorants do
Promote expulsion of bronchial secretions
Expectorants examples
Guaifenesin/ipecachuanha
Nasal decongestant examples
Pseudoephedrine
Who should compound preparations not be given to
Under 6 years old
Who should aromatic inhalations not be used in
Not advised for those <3 months
What should be used for blocked nose in infants
Saline nasal drops (give just before feeds to make feeding easier)
Who should cough suppressant be avoided in
Children under 6
What age can dextromethorphan be used
Children over 12
What cough drugs can’t be given otc for cough and cold in under 6’s
Chlorphenamic, diphenhydramine, promethazine, dextromethorphan , pholcodeine, guaifenasin, pseudoephedrine, ephedrine
How long should cough/cold preparation be taken in 6-12yo
5 days or less
Antihistamine respiratory use
Nasal allergies, allergic rhinitis (hayfever), vasomotor rhinitis
Other antihistamine uses
Urticaria, pruritis, insect bites/stings
What antihistamines are used in nausea and vomiting
Cinnarizine, cyclizine, promethazine
Sedating antihistamines
Alimemazine, promethazine most sedating but chlorphenamine and cyclizine have some effects
Non-sedating antihistamines
acrivastine, bilastine, cetirizine hydrochloride, desloratadine , fexofenadine hydrochloride , levocetirizine hydrochloride ), loratadine and mizolastine
Anaphylaxis treatment
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
Role of antihistamine in anaphylaxis
Chlorphenamine maleate IV/IM as adjunct after adrenaline
Role of corticosteroids in anaphylaxis
IV corticosteroid like hydrocortisone given secondary to initial management due to delayed onset it is used to prevent further deterioration
Treating continuing respiratory depression
Bronchodilators inhaled/IV salbutamol, ipratropium, aminophyline or IV magnesium
What to give on discharge after anaphylaxis
Oral corticosteroid and antihistamine for up to 3 days
Where to give IM adrenaline
Middle third of thigh
Treating angioedema
Treating angioedema
Treating hereditary angioedema
Not like normal use c1-esterase inhibitor, danazol and tranexamic acid used prophylactically
Asthma symptoms
Cough, wheeze, chest tightness, and breathlessness
Asthma treatment aims
No daytime symptoms, no night time awakening, no rescue medication, no exercise limitations, normal lung function (FEV/PEF 80% predicted)
Step 1 in asthma treatment
SABA( terbutaline, salbutamol) <1 a month
When to start low dose ICS maintenance
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
BTS recommendation for low ICS regimen
BD but can be OD if mild disease or complete control
Initial add on for Asthma (NICE/BTS)
Nice say LRTA, BTS say LABA and can use MART
When should leukotriene be evaluated
4 to 8 weeks
What is MART
Maintenance And Reliever Therapy—a combination of an ICS and a fast-acting LABA such as formoterol in a single inhaler
When to give initial add on
If asthma is uncontrolled on a low-dose of ICS as maintenance therapy
When to give initial add on
If asthma is uncontrolled on a low-dose of ICS as maintenance therapy
Additional add on NICE
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
Additional add on BTS
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
Additional add on BTS
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
