Respiratory- MEDIUM Flashcards
1
Q
What is asthma?
A
A chronic inflammatory disorder of the airways
An exaggerated bronchoconstrictor response to a wide variety of exogenous and endogenous stimuli
Recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early morning
2
Q
What are the treatment options for asthma?
A
- Beta 2 agonists
- Antimuscarinics
- Theophylline
- Corticosteroids
- Cromoglicate
- Leukotriene antagonists
- Omalizumab
3
Q
When is oral route for asthma considered for use?
Why is inhaled preferred?
A
When inhalation is not possible
Preferred because:
* Drug delivered directly to lungs (avoids first pass metabolism)
* Smaller dose required than with oral admin.
* Fewer S/E than with oral admin.
4
Q
What is the treatment pathway for asthma?
A
5
Q
What is COPD?
A
Chronic Obstructive Pulmonary Disorder (COPD)
- Airflow limitation, not fully reversible
- Usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases
6
Q
Who should be considered for COPD spirometry testing?
A
People over 35, current or ex-smokers, and have a chronic cough
7
Q
How is COPD diagnosed?
A
- The Medical Research Council dyspnoea scale graded breathlessness
- Post-bronchodilator spirometry to confirm diagnosis
- Chest radiograph to exclude other pathologies
- FBC to identify anaemia or polycythaemia
- BMI calculated
8
Q
What are the main points of COPD treatment?
A
- Smoking cessation!!
- Vaccinate against infection- can complicate COPD
- Pulmonary rehabilitation, if indicated
9
Q
What is the treatment pathway for COPD?
A
10
Q
When should LAMA+LABA or LABA+ICS be offered to patients?
A
- Have spirometry confirmed COPD
AND - Do not have asthmatic features
AND - Remain breathless or have exacerbations despite treatment for tobacco dependence, relevant vaccinations and use of a short acting bronchodilator
11
Q
When should LAMA+LABA+ICS be considered for patients already taking LABA+ICS?
A
- Those who’s symptoms continue to adversely impact their quality of life or have a severe exacerbation (requiring hospitalisation)
OR - Have 2 moderate exacerbations within a year
12
Q
When should LAMA+LABA+ICS be considered for patients already taking LABA+LAMA?
A
*Those having a severe exacerbation (requiring hospitalisation)
OR
*They have 2 moderate exacerbations within a year
13
Q
What is the advice surrounding oral corticosteroid use in COPD?
A
*Long-term use is not normally recommended
* Those with advanced COPD may need long-term oral corticosteroids, but the dose should be kept as low as possible
14
Q
What is a spirometry test?
A
Tests how an individual inhales or exhales volumes of air as a function of time
The primary signal measured in spirometry may be volume or flow
15
Q
Define Forced Vital Capacity (FVC)
A
Forced Vital Capacity (FVC)- the maximal volume of air exhaled with maximally forced effort from a maximal inspiration
16
Q
Define FEV1
A
Forced Expired Volume in one second (FEV1)- volume expired in the first second of maximal expiration after a maximal inspiration
17
Q
What is FEV1/FVC
A
FEV1 expressed as a percentage of the FVC, gives a clinically useful index of airflow limitation
18
Q
What is a clinically healthy FEV1/FVC?
And that of airflow limitation?
A
Healthy = 70-80%
Limited airflow = < 70%
19
Q
What are the benefits of spacers for inhalers?
A
- Suitable for children and elderly who find pMDIs difficult
- Reduces aerosol velocity, gives more time for evaporation of propellant therefore, larger proportion of particles reach target
- Useful for high dose ICS and patients prone to candidiasis (thrush)
20
Q
Points to consider for spacers?
A
- Size of spacer is very important, as well as size of face mask (if using)
- Replace spacer every 6-12 months
- Clean once monthly with mild detergent, air dry
- Inhale from spacer asap after activation as aerosol is short-lived
21
Q
What is the mode of action of sympathomimetics?
A
- Relax airway smooth muscle
- Inhibit mediator release
- Increase ciliary activity
Examples:
* Epinephrine (adrenaline)
* Isoprenaline (isoproterenol)
* β2 selective agents
22
Q
What is formoterol (Oxis, flutiformm symbicort)
typically indicated for?
A
- Chronic asthma
- Exercise-induced bronchospasm
23
Q
What is indacterol (Onbrez) indicated for?
A
COPD
- Improves the ability of patients with COPD to exercise
- Ultra-long acting and fast onset of action
- As effective as tiotropium bromide
24
Q
What is salbutamol (Salamol, Ventolin) indicated for?
A
Asthma and other conditions associated with reversible airways obstruction
Rapid onset of action; drug of choice as relief for symptoms of bronchospasm
25
What is salmeterol (Severent) indicated for?
* Prophylaxis of bronchospasm
* NOT for acute attacks, has long onset of action
26
What is terbutaline (Bricanyl) indicated for?
* Treatment of asthma and other conditions associated with reversible airways obstruction
27
What is the mode of action of beta-2 agonists?
Act directly on Beta-2 receptors, causing smooth muscle relaxation and dilation of the airways
28
What are the common S/E for Beta-2 agonists?
* Palpitations (less common with non-selective; vasodilation and reflex tachycardia; direct stimulation of β-2 in the heart)
* Hypokalaemia (K+ in skeletal muscle and in serum; tolerance)
* Fine tremor of skeletal muscle (hands)
* Nervousness, sleep disturbances
29
Where do Beta-2 agonists need to be used in caution?
* Hyperthyroidism
*CVD (HTN, arrhythmias, susceptibility to QT prolongation)
Diabetes (risk of ketoacidosis- glycogenesis in liver)
30
What is the mode of action of adrenaline (epinepherine)?
* Effective and rapidly acting bronchodilator (inh/SC)
* Simulates Beta-1+2 receptors (non-selective)
31
Common S/E of adrenaline?
* Tachycardia
* Arrhythmia
* Dry mouth
* Insomnia
* Restlessness
32
What are adrenaline's uses in emergencies?
* Acute allergic reactions (anaphylaxis)
* Angioedema
* Management of severe croup (RTS- seal coughing in children)
* Cardiopulmonary resuscitation
33
What is the mode of action of antimuscarinic bronchodilators?
* Reduce vagal cholinergic tone, the main reversible component of COPD
* Inhibit the effect of acetylcholine at muscarinic receptors
* Block contraction of airway smooth muscle
* Block the secretion of mucus
34
Give an example of a naturally occurring antimuscarinic
Atropine
35
Give examples of synthetic antimuscarinics
* Ipratropium bromide
* Oxitropium bromide
* Tiotropium bromide
36
When should antimuscarinic therapy be used in caution?
* Glaucoma
* Prostatic hyperplasia
* Bladder outflow obstruction
37
What is ipratropium indicated for?
* Short term relief in chronic asthma (SABA preferred)
Can be added if asthma fails to improve with standard therapy
* Short-term relief in COPD (if not on LAMA)
Onset is 15-30 mins
Maximum effect is 60-90 mins after admin. (COPD)
38
What is aclidinium (Eklira) indicated for?
Maintenance for COPD (not suitable for acute bronchospasm)
39
What is glycopyronium bromide (Seebri) indicated for?
Maintenance therapy for COPD and hyperhidrosis (excessive sweating)
40
What is tiotropium (Spiriva) indicated for?
Dosing regimen?
* COPD maintenance- 18mcg OD
* Once daily dosing
* Maximum effect 90-120 mins after inhalation
Spiriva RESPIMAT restricted for use in COPD for patients with poor manual dexterity
41
What are the common S/E for tiotropium?
* Dry mouth
* GI motility (diarrhoea, constipation)
* Cough
* Nausea
* Angle closure glaucoma
42
Under what class does Theophylline fall under?
What do these class of med do?
Any downsides?
Xanthines
* Have bronchodilator and anti-inflammatory effects
* β2 agonists are more effective as bronchodilators and corticosteroids have greater anti-inflammatory effect
43
Points to consider for theophylline therapy?
* Despite extensive use in respiratory disease, molecular action not fully understood
* Metabolised by CYP450
* Has a very narrow therapeutic window (requires close monitoring)
44
What is the effective therapeutic window for theophylline?
Plasma conc. : 10-20 mg/L
Doses must be adjusted in individual patients according to their their plasma concentration
45
What are the monitoring requirements for theophylline?
Plasma concentration
46
What can cause increases plasma concentrations of theophylline?
* Heart failure
* Hepatic impairment
* Viral infection
* Elderly
47
What can cause a decrease in plasma concentrations of theophylline?
* Smokers
* Alcohol consumption
48
Does prescribing need to be by brand on theophylline?
What is the most common brand?
Yes- the rate of release from MR preps varies
If no brand mentioned on Rx- contact prescriber
Most common- Uniphyllin Continus
49
What is the MAX dosing for theophylline?
400mg 12-hourly
50
What are the S/E associated with theophylline?
* CNS: increased alertness, insomnia, tremor, headache
* CVD: inotropic and chronotropic positive effects tachycardia
* GI: stimulates gastric acid secretion, anorexia, nausea, vomiting, gastro-oesophageal reflux
* Kidney: diuretic
* Smooth muscle: Bronchodilation
51
What decreases the metabolism of theophylline?
and therefore increases serum concentration
* Old age
* Arterial hypoxemia (low oxygen sat.)
* Respiratory acidosis
* Congestive cardiac failure
* Liver cirrhosis
* Erythromycin
* Quinolone antibiotics
* Cimetidine (NOT ranitidine)
* Viral infections
* Herbal remedies (St. John's Wort)
52
What increases the metabolism of theophylline?
and therefore decreases serum concentration
* Tobacco smoking
* Alcohol
* Anticonvulsant drugs
* Rifampicin
53
What is aminophylline?
Differences to theophylline?
Theophylline + ethylenediamine
* Given by very slow IV infusion
* Too irritant for IM use, 20x more soluble than theophylline
54
Does branded prescribing need to take place?
Yes- MR preps vary in rate of release
55
When should phylloctonin continus forte tablets (aminophylline) be used?
In patients where theophylline has a shorter half life
56
What is the most common compound bronchodilator preparation?
What is it indicated for?
Combivent: 500mcg
* Ipratropium + 2.5mg salbutamol
Indicated for bronchospasm in COPD
57
When and why is use of compound bronchodilator therapy used?
When patients are stable on both constituent drugs
Used because it is best to treat with single drug- can adjust dose more easily
58
What is the benefit of nebulisers?
Delivers a greater proportion of the drug to the lungs compared with standard inhalers
59
When should nebulisers be used with caution?
* Acute angle-closure glaucoma associated with nebulised drugs i.e. ipratropium
* NB: eye care during nebulisation
60
What are nebulisers indicated for?
* Beta-2 agonist or ipratropium in acute exacerbation asthma
* Beta-2 agonist, corticosteroids ipratropium in severe asthma
* Antibiotic or mucolytic in cystic fibrosis
* Budesonide or adrenaline to child with severe croup
* Pentamidine for treatment/prophylaxis of pneumocystis pneumonia
61
What is the mode of action of corticosteroids?
More specifically in respiratory care?
* Once in the cell they bind to specific receptors in the cytoplasm- 'activated glucocorticoid-receptor complex' translocates to the nucleus to interact with the DNA
* This induces transcription of particular genes and synthesis of some proteins and vice versa
In respiratory care:
* Transcription of various pro-inflammatory gene products are modified
* This reduces airway inflammation and hyper responsiveness
62
How are inhaled corticosteroids (ICS) used in asthma?
Effects of regular ICS use?
* They reduce airway inflammation, oedema and secretion of mucus
* ICS used prophylactically if Beta-2 agonist required > 2 weeks, or if sleep disturbances or exacerbations in last 2 years requiring systemic CS
* Regular use reduces risk of exacerbation
* Smoking reduces effectiveness of CS
63
How are ICS used in COPD?
CS reduce exacerbations when combined with LABA
64
What can high doses of ICS lead to?
* Adrenal suppression
* Associated with pneumonia in elderly with COPD
65
What can long-term treatment with ICS leads to?
Reduced bone mineral density, predisposes to osteoporosis
Height of children on prolonged treatment should be monitored
66
What are the common S/E of ICS?
* Hoarseness, dysphagia, throat irritation, oropharyngeal candidiasis
* Hyperglycaemia with high doses
* Anxiety, depression, sleep disturbances
67
How can patients manage oral candidiasis?
* Reduce risk by using spacer and rinsing mouth/ brushing teeth after use
* Antifungal oral gel can be used to treat OTC without stopping treatment
68
Give 5 examples of ICSs
* Beclomethasone (Becotide)
* Budesonide (Pulmicort)
* Fluticasone (Flixotide)
* Mometasone (Asmanex)
* triamcinolone (Nasacort)
69
What are the systemic S/E associated with long-term, high dose treatment with ICS?
* Skin thinning, easy bruising
* Glaucoma, cataracts
* Adrenal suppression
* Slow growth rate in children
* Low bone mineral density --> osteoporosis
70
How does poorly controlled asthma affect a foetus during pregnancy?
* Low birth weight
* Increased perinatal mortality
* Prematurity
* Risk of foetal hypoxia
71
How are acute exacerbations controlled in asthmatic pregnant patients?
* SABA- nebulised
* Oxygen
* Systemic glucocorticoid therapy, when necessary
72
What is the mode of action of leukotriene receptor antagonists?
* Block effect of cysteinel leukotrienes on airway
* Improve lung function and reduce asthma exacerbations
73
What are the effects of leukotrienes?
* Increase in microvascular permeability (oedema)
* Increased mucus secretion
* involved in smooth muscle proliferation and remodelling
* Increased infiltration of eosinophils into airways
74
What are the side effects associated with leukotriene receptor antagonists?
* Churg Strauss Syndrome
* GI upset
* Headache
75
Give an example of a leukotriene receptor antagonists and its dosing regimen
Montelukast- 10mg at night
5mg at night for child < 15 y/o
76
What is Churg Strauss Syndrome?
How can it be spotted?
An autoimmune disorder marked by blood vessel inflammation (vasculitis)
Monitor for signs of eosinophilia, vascularitic rash, peripheral neuropathy and cardiac complications
77
What is the mode of action of phosphodiesterase type-4 inhibitors?
* Prevent activation of the intracellular cyclic adenosine monophosphate (cAMP)/ cyclic guanosine phosphodiesterase (cGMP)
* May improve lung function, decreasing inflammation around the small airways
78
What is roflumilast indicated for?
Adjunctive therapy to bronchodilators (severe COPD)
Has anti-inflammatory activity
79
S/E associated with roflumilast?
* Increased risk of psychiatric disorders: insomnia, anxiety, nervousness and depression
* Diarrhoea, nausea, abdominal pain
* Headache
80
When is roflumilast contra-indicated?
* Moderate/severe hepatic impairment
* Immunological diseases
Not recommended if psychiatric symptoms
81
When are antihistamines used in caution?
Epilepsy- can increase seizure susceptibility
82
Where must antihistamines be avoided?
Patients with severe liver disease- increased risk of coma
83
What is the mode of action of H1 receptor antagonists?
They bind competitively bind to H1 receptors present on nerve endings, smooth muscle and glandular cells
84
What are H1 receptor antagonists indicated for? (5)
* Allergic rhinitis/ allergic conjunctivitis
* Urticaria (hives)
* Drug hypersensitivity
* Anti-emetic
* Sedation
85
S/E associated with H1 receptor antagonists? (4)
* Sedation
* Tinnitus
* Dizziness
* Antimuscarinic S/E e.g. dry mouth, constipation etc
86
Counselling points for antihistamines?
Do not drive/ operate heavy machinery
87
Adverse effects associated with antihistamines?
Children and elderly more prone to S/E
* Drowsiness
* Paradoxical stimulation (opposite effect of drug)
* Headache
* Psychomotor impairment
* Antimuscarinic S/E (dry mouth, urinary retention, blurred vision, GI upset)
88
Examples of non-sedating vs sedating antihistamines
89
What is the principle behind allergen immunotherapy?
Vaccines containing allergens i.e. house dust, cat dander, can reduce asthma symptoms
Vaccines with wasp, bee venom reduce anaphylaxis
90
What is Omalizumab and its mode of action?
a monoclonal antibody that binds to immunoglobulin E, mitigating its allergic reaction effects on the body
91
What is Omalizumab indicated for?
Severe, persistent asthma uncontrolled with ICS
92
S/E associated with Omalizumab?
Associated with Churg Strauss Syndrome
* Injection side reactions
* Rash, diarrhoea, nausea, vomiting, menorrhagia, epistaxis (nose bleed)
93
How is anaphylaxis characterised, and how is it treated?
* A severe, life-threatening, systematic hypersensitivity reaction
* Rapid cardiopulmonary symptoms
Adrenaline licenced for emergency treatment of acute anaphylaxis (angioedema, cardiopulmonary resuscitation)
94
How should patient-carried adrenaline pens be administered?
What are next steps should anaphylaxis not resolve?
* Lie patient flat
* Raise legs (put in recovery position if nauseous)
* Administer adrenaline into thigh
* Should reverse immediate symptoms associated with hypersensitivity
* Second dose should be 5-15 mins after, if first is unsuccessful
* Continuous respiratory deterioration requires treatment with bronchodilators i.e. inhaled, IV salbutamol, ipratropium, IV aminophylline
95
What are the potential risks causing anaphylaxis reactions?
* Insect stings
* Medication (e.g. NSAIDs, vaccines, neuromuscular blockers, latex)
* Milk, eggs, fish, shellfish, soya
* Arachis oil, other excipients
96
3 examples of adrenaline pens
* Epipen
* Anapen
* Jext
97
What are respiratory stimulants?
Stimulate respiratory and non-respiratory muscles (can be harmful). Only effective given IV, and have a short duration of action. Expert supervision required
98
What is Doxapram HCl indicated for?
* Post operative respiratory depression
* Acute respiratory failure
99
What is Caffeine citrate indicated for?
Neonatal apnoea (specialist supervision in hospital)
100
What is the mode of action of pulmonary surfactants?
They reduce the surface tension at the air/water interface in the alveoli, thereby preventing collapse of these structures at end-expiration. Also enables the lung to inflate more easily, reducing workload
101
What are pulmonary surfactants indicated for?
Give 2 examples of these
Respiratory Distress Syndrome in neonates
Examples:
* Baractant
* Poractant alfa
102
How is oxygen generally indicated?
What is its mode of action?
For hypoxemic patients, prescribed to achieve near-normal oxygen saturation (Aim: 94-98%)
* Increases alveolar oxygen tension
* Reduces workload of breathing
103
In which medical conditions is high conc. oxygen suitable?
* Pneumonia
* Sepsis
104
Points to consider for oxygen therapy
* Consider smoking cessation before starting oxygen
* Discuss with airlines before travelling abroad
* Concentration used depends on condition being treated
105
What is the mode of action of mucolytic drugs?
Where do they need to be used in caution?
What else could be used to the same effect?
Facilitate expectoration of mucus by reducing sputum viscosity
They disrupt the mucosal barrier, use in caution in peptic ulcer/ history of ulcer
Steam inhalation could also be effective
106
S/E associated with carbocisteine?
At what age is it licenced for?
GI side effects
Used from 2 years old on
107
What is erdostine indicated for?
S/E?
Treat acute exacerbations of chronic bronchitis
GI S/Es
108
What is Dornase Alfa?
It's function and indication?
Genetically engineered enzyme- glycosylated recombinant human rhDNAse
Cleaves extracellular DNA
Increase lung function, used in cystic fibrosis
109
How is Dornase Alfa administered, and how often?
* Admin. with jet nebuliser
* Up to BD
110
What is Ivakaftor (Kalydeco) indicated for?
How is this identified?
Cystic fibrosis in patients with G551D mutation in CFTR gene
Genotyping method should be performed to confirm G551D mutation in at least one allele
111
What are the monitoring requirements for ivakaftor?
LFTs prior to treatment, also be checked every 3 months during first year of treatment, then annually thereafter
112
S/E associated with ivakaftor?
* Abdominal pain
* Nausea
113
Dosing schedule with ivakaftor?
BD dosing- reduce dose if taking with "-zoles" or "-mycins"
114
What is mannitol indicated for and its administration method?
Cystic fibrosis- non-responsive to Dornase Alfa
Administered by inhalation
115
What is the mechanism of action of mannitol?
Not fully understood but improves mucus clearance
116
What are the potential causes of a cough?
* GORD
* Chronic bronchitis
* Rhinitis, rhinosinusitis, post natal drip syndrome
* a S/E of ACEi!!
* Associated with smoking, environmental causes e.g. pollution
117
What are the respective lengths of acute and chronic coughs
* Chronic cough- > 8 weeks
* Acute cough- < 3 weeks
118
Recommendations for acute cough management
* Acute viral cough often self-limiting and doesn't require treatment
* Simplest and cheapest option may be 'home remedy' like honey and lemon
* Opiate antitussives have significant adverse effect profiles so aren't recommended
119
Examples of expectorant cough medicines
Guaifenisin, ipecacuana
120
Examples of suppressant cough medicines
Dextromethorphan, pholcodeine, codeine
121
Examples of decongestant cough medicines
Phenylephrine, pseudoephedrine, oxymetazoline, xylometazoine
122
Examples of antihistamine cough medicines
Chlorphenamine, diphenhydramine, doxylamine, promethazine, tripolidine
123
At what age should people not be offered liquid codeine as antitussive?
< 18 years old
124
At what age should people not be offered couh and cold remedies?
< 6 years old
125
Give an example of a systemic nasal decongestant
Pseudoephedrine (Sudafed)
126
Advantages and disadvantages of systemic nasal decongestants
Advantage- not associated with rebound congestion
Disadvantage- not as effective as local decongestant
127
When does pseudoephedrine need to be used in caution?
* Diabetes
* Hypertension
* Hyperthyroidism
* Ischaemic heart disease
128
S/E associated with pseudoephedrine
* Nausea
* Vomiting
* Tachycardia
129
Typical dosing schedule for pseudoephedrine
60mg TDS-QDS
130
Which high risk drugs can be used in cough suppression in palliative care?
Methadone
* Licenced for cough in terminal illness
* Long duration of action, accumulates
Morphine
* Shorter acting
