Respiratory bits and pieces! Flashcards
Acute asthma management - ADULTS
Moderate - Home or in primary care => hospital if inadequate response; treatment: high dose SABA (8 - 10 puffs) via PMI and spacer
Severe or life-threatening - Hospital STAT; treatment: high dose SABA via O2 driven nebuliser +/- nebulised ipratropium
Near-fatal or life-threatening with a poor response to initial therapy - IV aminophylline
ALL PATIENTS: PO prednisolone 40 - 50mg OD for at least 5 days; if inappropriate: IV hydrocortisone or IM methylprednisolone
Hypoxaemic pts: supplementary 02 (maintain Sp02 between 94 - 98%)
Acute asthma management - KIDS
2 years and over:
- severe or life-threatening => hospital STAT (O2 in life-threatening acute asthma or SpO2 < 94%)
- 1st line: SABA; if mild - moderate: PMI + spacer => medical attention if symptoms aren’t controlled with up to 10 puffs; severe or life-threatening => via an O2 driven nebuliser
ALL CASES: PO prednisolone for 3 days
Poor initial response to Beta2 agonist => add nebulised IPRATROPIUM
In poor response to 1st line treatments => IV MgSO4
Under 2 years:
- HOSPITAL STAT
- moderate - severe => O2 STAT + SABA trial
- if required, combine nebulised IPRATROPIUM BROMIDE
ASTHMA PATHWAY - ADULTS
1.
Intermittent Reliever (SABA)
2.
SABA + Low dose ICS:
Start ICS if asthma is uncontrolled by SABA alone (use SABA 3x OW, symptoms 3x OW, nighttime awakening at least OW, using >1 inhaler/month)
3.
SABA + ICS + X
- NICE = LTRA
- BTS/SIGN = LABA - a fixed-dose OR as a MART (e.g. FOSTAIR inhalers, SYMBICORT etc.)
4.
+ LABA if already not added
- can be given w/ or w/o LTRA
- can convert fixed-dose LABA + moderate strength ICS into MART
5.
Increased strength to high strength ICS or initiate (specialist)
- theophylline
- tiotropium
- PO corticosteroids
- monoclonal Abx
ASTHMA PATHWAY - KIDS > 5 years
1.
SABA
- SABA + ICS - very low strength in paeds
- SABA + ICS + X
- NICE = LTRA
- BTS/SIGN = LABA (if 12+)
4.
Replace LTRA w/ LABA if not already on LABA
- can be given as MART if still no change
5.
Increase ICS strength and initiate (specialist)
- theophylline
- tiotropium - 12 years +, if under, can give theophylline OR PO B2 agonist (Bambuterol)
- PO corticosteroids
- monoclonal Abx
ASTHMA PATHWAY - KIDS < 5 years
1.
SABA - if using more than 1 device/month = REFER
- SABA + ICS - very low strength in paeds
- start if asthma is uncontrolled by SABA alone (symptoms 3x OW, night-time awakening at least OW)
- use paeds low dose for an 8 week trial to see if it works b4 cont
- if ICS not tolerated = a LTRA can be used instead
3.
SABA + ICS + LTRA
- if still not controlled => stop LTRA and refer to specialist
ASTHMA PATHWAY - dropping down
- when asthma has been controlled for at least 3 months
- pts maintained at the lowest possible dose of ICS => reductions considered every 3 months - 25 - 50% each time
COPD PATHWAY
OFFER PNEUMOCOCCAL & INFLUENZA VACCINES!
- SABA or SAMA
- cont SABA throughout stages
2a. Asthmatic or features suggesting steroid responsiveness
LABA + ICS. Discont SAMA
2b. Non-asthmatic
LAMA + LABA. Discont SAMA
- LAMA + LABA + ICS
if pt has a severe exacerbation or 2+ moderate ones in a year
4a. Asthmatic or features suggesting steroid responsiveness
Theophylline MR
O2 therapy => severe COPD w/ hypoxemia - 15h OD at 88 - 92% saturation - must carry O2 alert card and use a 24% or 28% Venturi mask if a history of hypercapnia respiratory failure
mucolytics
4b. Non-asthmatic, feels no change after 3 months
Revert back to LAMA + LABA
COPD Infective Exacerbations - Rescue pack
Pts are eligible if they had an exacerbation within last year
- PO corticosteroid + Abx:
- Amoxicillin 500mg TDS for 5 days
- Doxycycline 200mg STAT for 1 day, then 100mg OD for 5 days
- Clarithromycin 500mg BD for 5 days - AVOID if taking prophylactic azithromycin 500mg OD across M, W, and F.
Non-drug treatment: positive expiratory pressure helps sputum clearance
COPD Exacerbations - Further drug treatment
- Bronchodlator therapy: SABA/SAMA = withhold LAMA treatment if a SAMA is given
- Hospitalised: short course of prednisolone along with other therapies
- Community: short course of prednisolone if significant breathlessness
PREDNISOLONE 30mg OD for 7 - 14 days
- IV Aminophylline: added if there’s an inadequate response to nebulised bronchodilators
- O2: to keep O2 sats of arterial blood levels in range
LABA + LAMA + ICS inhalers
- TELEGY ELLIPTA (DPI) = vilanterol + meclidinium + fluticasone - 1 puff OM
- Trimbow (MDI) = Formoterol + glycopyrronium + beclomethasone - 2 puff BD
SABA / LABA
SABA: Salbutamol, Terbutaline (4h) - 1-2 puffs QDS - 8 puffs max OD
LABA: Salmeterol (BD), Formoterol (BD), Vilanterol (w/ umeclidinium - COPD (Anora Ellipta); w/ fluticasone - asthma (Relvar Ellipta)) (12h)
Bambuterol - PO B2 agonist tablet
LABAs: Don’t start in rapidly deteriorating asthma as it isn’t licensed for monotherapy - it can increase the incidence of mortality
Salmeterol: LONG ONSET + LONG ACTION
Formoterol: SHORT ONSET + LONG ACTION - r/v if using more than OD; can be used as relievers in addition to regular use as preventer in MART!
Brands: SYMBICORT is 18+
Caution: DM as can cause DKA after IV administration, and hyperthyroidism
Increase risk of arrhythmias and other CVS events
Increased risk of digoxin toxicity due to hypokalaemia
SE:
- Fine tremor, palpitations, tachycardia, hyperglycaemia headache, seizure, anxiety
- Cause hypokalemia (more common in IV/nebulisers) - increases the risk of QT prolongation - corticosteroids, diuretics, theophylline, other B2 agonists, and hypoxia in severe asthma
SAMA / LAMA - relaxes smooth muscle of bronchi to cause bronchodilation
SAMA: ipratropium (TDS) - maximal effects between 30 - 60mins; duration of action = 3 - 6h
LAMA: tiotropium - Spiriva Respimat - only LAMA license in asthma, aclidinium, glycopyrronium - Seebri Breezhaler, umeclidinium - OD except for Eklira - aclidinium (BD)
Cautions:
- prostatic hyperplasia (BPH = prostate gland enlargement) and bladder outflow obstruction - worsened urinary retention reported
- risk of angle-closure glaucoma - acute angle-closure glaucoma reported w/ nebulised ipratropium, esp when given with salbutamol. PROTECT EYES.
- Spiriva Respimat - caution in pts w/ arrhythmias
- CKD 3+ = risk of drug toxicity
SE: antimuscarinic complications (parasympathetic pathway!!!) - constipation, dry mouth (most common), increased ocular pressure (report halos or blurred vision), paradoxical bronchospasm, abnormal taste, nasal congestion, nasal dryness
Interactions: other antimuscarinic drugs
ICS
Beclometasone, budesonide, ciclesonide (OD), fluticasone, mometasone (BD or OD) - all BD apart from ciclesonide
- Beclometasone - BRAND
- QVAR and Kelhale have extra-fine particles and are 2x stronger than inhalers
- Fostair (keep in fridge) (beclometasone/formoterol) has extra fine particles and is MORE potent than Qvar and Clenil Modulite.
- QVAR: 12+
- Easyhaler: 18+
- steroid cards
Monitoring in kids: height and weight in prolonged treatment monitored manually. Slow growth = paeds referral!
SEs:
- taste and voice alteration = hoarse voice
- sore mouth and throat - candidiasis => reduced by using spacer and rinsing mouth with water after => antifungal treatment w/ MICONAZOLE (Daktarin gel)
- Smoking - increased ICS dose as current and previous smoking can reduce the ICS effectiveness
- paradoxical bronchospasm: MILD = prevented by inhalation of a SABA beforehand OR change from an aerosol inhalation to a DPI
LTRA
Montelukast ON (Zafirlukast has been discontinued) - bronchodilator within 2h, and anti-inflammatory effect seen within 4wks!
Zafirlukast = liver toxicity, hence, report signs of it!
SEs:
- GI disturbances
- MHRA warning: risk of neuropsychiatric reactions - seek medical attention if speech and behavioural changes occur
- Churg-Strauss Syndrome - eosinophilia, vasculitis rash, worsening pulmonary symptoms, cardiac complications, or peripheral neuropathy. This mainly happens on withdrawal or reduction of oral cortricosteroid
Interactions: CYP450 enzyme substrate
Theophylline - xanthine bronchodilator
IV aminophylline (mixture of theophylline/thylenediamine) - 20x more soluble and too irritant to give IM
10 - 20 mg/L
Plasma levels:
- 4-6h post dose
- 5 days after beginning treatment
- at least 3 days after a dose adjustment
Brands don’t have the same bioavailability: BRAND
Toxicity: SICK AND FAST - like CAFFEINE
- V and GI effects initially (diarrhoea, gastric irritation)
- tachycardia, CNS stimulation (restlessness, agitation, dilated pupils)
- arrhythmias, convulsions, hypokalemia = more serious!
SEs: V, tremor, palpitations, arrhythmias
Cautions: CVD, hyperthyroidism, HT
Interactions:
Conc increased = HF, hepatic impairment, viral infections, elderly, enzyme inhibitors. Drugs: verapamil, CCB, cimetidine, phenytoin, fluconazole, macrolides
Conc decreased = smokers, alcohol, enzyme inducers. Drugs: St John’s Wort, rifampicin
- hypokalemia => SABA/LABA, duretics, corticosteroids
- Convulsions risk => quinolones + theophylline. Quinolones are enzyme inhibitors and can lower the seizure threshold. Theophylline’s SE is convulsions!
- smoking = smoking increases theophylline CL and reduces absorption, thus, increasing dosage, however, this needs to be decreased when someone stops smoking
- fevers = reduce theophylline CL
CROUP
Mild:
Single PO DEXAMETHASONE dose oral solution
Moderate - severe:
- hospital admission
- single dose of DEXAMETHASONE or PREDNISOLONE given PO whilst awaiting admission
- if can’t take PO: IM DEXAMETHASONE or NEBULISED BUDESONIDE
- severe not controlled by steroids: NEBULISED ADRENALINE / EPINEPHRINE
ALLERGIES - antihistamines - binds to H1 receptor site to block the action of histamines
1st gen: more sedating + antimuscarinic
- allimemazine, promethazine (BD/TDS) MORE sedating than chlorphenamine (QDS) and cyclizine
2nd gen: less sedating + less psychomotor impairment
- acrivastine (TDS), cetirizine (OD), desloratadine, loratadine (OD), fexofenadine (OD)
SE: AVOID alcohol as driving may be impaired
Cautions:
- benign prostatic hyperplasia - urinary retention
- glaucoma - raised intraocular pressure
- severe liver impairment - sedation precipitates hepatic coma
Used in N/V, migraines, insomnia:
- N/V: cinnarizine, cyclizine, promethazine HCL, promethazine TEOCLATE
- migraine: Buclizine (BUCCASTEM) OTC
- occasional insomnia: 1st gen promethazine HCL AND diphenhydramine OTC
- Adjunct in emergency anaphylaxis and angioedema: chorphenamine / promethazine injection
Antihistamine - HYDROXYZINE - 1st gen
MHRA: QT prolongation + Torsade de pointes
Use: Short term only. Max dose is 100mg OD in adults, 50mg OD in elderly.
CIs:
- risk factor for QT prolongation
- concomitant drugs that prolong QT prolongation
- CVS disease
- FH of sudden death
- HYPOkalaemia
- HYPOmagnesaemia
- bradycardia
ALLERGIES - allergen immunotherapy
Hypersensitivity to wasp and bee stings => allergen vaccines containing wasp and bee venom extract
Allergic rhinoconjunctivitis, reducing allergic asthma symptoms => allergen vaccines containing house dust mite, cat or dog dander, grass or tree pollen extracts
AVOID in:
- asthma or use with caution
- pregnant women
- kids < 5 years
- BB
- ACEi
Omalizumab
- monoclonal antibody that binds to IgE
- if severe persistent allergic asthma can’t be controlled adequately with ICS + LABA in 6+
- Chronic spontaneous urticaria in 12+
- SE’s: Churg-Strauss syndrome and hypersensitivity reaction
Anaphylaxis - EMERGENCY STEPS
- Use auto-injector STAT - IM adrenaline/epinephrine to the midpoint of the outer thigh
- STAT call 999 and state anaphylaxis - administer CPR PRN
- Lie down and raise the pts legs
- remove the trigger causing the anaphylactic reaction if possible
- repeat after a 5min interval if there is no improvement in the pts condition
Anaphylaxis - hospital treatment
- High-flow O2 given ASAP
- IV fluids given when there’s hypotension/shock
- After stabilisation, a non-sedating PO antihistamine, e.g. cetirizine HCL - if PO not available, give IM or IV chlorpheniramine maleate - this is to counter histamine-mediated vasodilation and bronchoconstriction
- Inhaled bronchodilator therapy w/ SALBUTAMOL or ipratropium may be considered for pts with persisting respiratory problems
- HYDROCORTISONE injection to prevent further deterioration in severely affected pts
ANAPHYLAXIS - kid up to 6 months
MHRA: 2 auto-injectors should be prescribed and carried at all times; check expiry dates and obtain replacements before expiry
100 - 150mcg
ANAPHYLAXIS - 6 months - 5 years
MHRA: 2 auto-injectors should be prescribed and carried at all times; check expiry dates and obtain replacements before expiry
150mcg
ANAPHYLAXIS - 6 - 11 year
MHRA: 2 auto-injectors should be prescribed and carried at all times; check expiry dates and obtain replacements before expiry
300mcg
ANAPHYLAXIS - 12 years +
MHRA: 2 auto-injectors should be prescribed and carried at all times; check expiry dates and obtain replacements before expiry
500mcg
Cystic fibrosis
- mucolytic (facilitates expectoration by reducing sputum viscosity)- DORNASE ALFA - helps clear mucus or sputum from lungs
CI: active peptic ulcers as mucolytics disrupt gastric mucosa - long-term antibacterial considered to suppress chronic S.Aureus
- PANCREATIN: nutrition and exocrine pancreatic insufficiency
- Monitor pts for liver disease, DM, and bone density
pMDI
Inhale SLOWLY and DEEPLY
DPI
Inhale STRONGLY and DEEPLY
