Respiratory System Flashcards
What is chronic asthma
reversible obstructive airways
What are Chronic Asthma symptoms
- coughing (usually at night)
- shortness of breath
- chest tightness
- wheezing
Chronic Asthma 1st line
Short Acting Bronchodilators (SABA)
- Salbutamol
- Terbutaline
alternative…
- ipratropium bromeide (SAMA)
- Theophylline (if 12 or above)
Why move to second line in chronic asthma management
- if using inhaler/symptomatic at least 3 times a week
- getting night time symptoms at least once a week
- asthma attack requiring steroids within 2 years
Chronic Asthma 2nd Line
- Low dose inhaled corticosteroids (BD, reduce to OD if well controlled)
(mometasone, fluticasone, beclometasone, budesonide)
What are alternative 2nd Line treatments for chronic asthma
- inhaled sodium cromogliate
- leukotriene receptor antagonist (montelukast)
- Theophylline
Chronic Asthma 3rd Line treatment
Long acting Bronchodilators + Inhaled corticosteroid
LABA
- serevent
- foradil (formoterol)
Combination Inhalers with both
- Fostair
- DuoResp
- Seretide
- Symbicort
Chronic Asthma 4th Line treatment:
Part 1
If no response for 3rd Line:
Stop LABA
and…
Increase ICS dose
Chronic Asthma 4th Line treatment:
Part 2
If benefiting, but still inadequate;
continue LABA
Increase ICS dose
or…
trial LAMA (tiotropium bromide), LTRA or Theophylline
Chronic Asthma 5th Line treatment
High dose ICS + fourth drug…
- Theophylline
- LAMA (tiotropium bromide)
- LTRA
- Oral B2 agonist tablet (bambuterol)
Chronic Asthma 6th Line treatment
short dose oral corticosteroid (5 days for adult and 3 days or child 6 to 12)
for potent asthma events
What is a selective B2 agonist (SABA and LABA)
drug that causes bronchodilation of the bronchi
Inhaled Short-Acting B2 Agonist examples
Salbutamol
Terbutaline
(both QDS PRN)
3-5 hour onset
Inhaled Long-Acting B2 Agonist examples
Formoterol
Salmeterol
(both BD)
12 hour onset
Other Long Acting B2 Agonist examples and what are they for
- Olodaterol (COPD)
- Indacterol (COPD)
- Vilanterol (Anoro Elipta)
Example of an Oral B2 agonist oral tablet
Bambuterol
When should you not initiate a LABA
in a patient with rapidly deteriorating asthma
What type of onset is Salmeterol (LABA) and what is it not for
Long onset + Long action
not for…
- acute asthma relief
- prevention of exercise induced asthma
What type of onset is Formeterol (LABA) and what is it used for
Short Onset + Long Action
Used as a reliever in addition as a preventer
Examples of Combined Inhalers and what LABA do they contain
Fostair, DuoResp, Symbicort, Luforbec, Trimbow
Formeterol
Examples of LABA inhalers
- Serevent (salmeterol)
- Foradil (formoterol), - - Striverdi (olodaterol)
Examples of SABA inhalers
- Salamol
- Ventolin
- Bricanyl (terbtaline)
Examples of Inhaled Corticosteroid Inhalers
Beclometasone Inhaler brands
- QVAR
- Beconase
- Clenil Modulite
- Kelhale
- Soprobec
Mometasone Inhaler Brands
- Nasonex
- Elocon
Short-Acting B2 Agonist (SABA) side effects
- hand tremors
- tachycardia
- hyperglycaemia
- hypokalaemia
- Serious cardiovascular events
When prescribing Inhaler always make sure to…
explicitly state dose, frequency and max puffs in 24 hours
What are spacers when used with inhalers
Spacers take up the medication and holds it for the patient to inhale easier
More information on SABA Side Effect: Hypokalaemia
Hypokalaemia can be increased via…
SABA + corticosteroid / other b2 agonists / theophylline
monitor serum potassium
More information on SABA Side Effect: Cardiovascular Events
- Prolonged QT interval
- arrhythmias
- tachycardia
- arterial hypoxia (not enough oxygen for homeostasis)
- myocardial infarction
- hypotension
tale caution in hyperthyroidism
Inhaled Corticosteroid (ICS) mode of action
reduces inflammation in the bronchi
Inhaled Corticosteroids examples and how often to take
BD dosing…
- beclometasone
- budesonide
- fluticasone
OD dosing…
- ciclesonide
BD an OD dosing…
- mometasone
How to long should someone take Inhaled corticosteroids for prevention of asthma
3 - 4 weeks
What does CFC free mean stand for in inhalers
free from chlorofluorocarbons
Most potent and fine beclometasone cfc free inhalers
Least Potent/Least fine
Clenil Modulite
Qvar
Fostair
Most Potent/Most Fine
Qvar minimum age
12+
Any Easyhaler minimum age
18+
Inhaled Corticosteroid side effects
- hoarse voice
- sore throat
- oral candidiasis
- paradoxical bronchospasm
Inhaled Corticosteroid Side effect: Oral Candidiasis advice and treatment
Counselling
- rinse mouth and brush teeth after use, or use a spacer
Treatment
- Daktarin Gel (miconazole get)
… do not use warfarin
Inhaled Corticosteroid Side effect: paradoxical bronchospasm what to do
Stop the ICS and give alternative
if only mild…
- transfer from pMDI to dry powder inhaler
What are the NICE guide lines on who should use large-volume spacers
- patients with high does ICS
- patients under 15
What lifestyle activity reduces the effectiveness of ICS
Current or previous smoking
may need higher dose
When to consider giving a patient a steroid card
if their corticosteroids dose is greater than max licensed dose
Leukotriene Receptor Antagonists mode of action
blocks action of leukotriene on the cysteinyl leukotriene receptor in the lungs and bronchi. This reduces bronchoconstriction and inflammation
Examples of Leukotriene Receptor Antagonists
Montelukast
Zafirlukast
Leukotriene Receptor Antagonists Side effects
- churg strauss syndrome (blood vessel inflammation) (cardiovascular symptoms)
Leukotriene Receptor Antagonists Side effects: Specifically Zafirlukast
Liver toxicity
Patient Counselling:
report symptoms such as:
- nausea
- vomiting
- jaundice
- abdominal pain
- itching
Theophylline (Xanthine Bronchodilator) example
IV Aminophylline
(theophylline and ethylenediamine) is 20x more soluble
Signs of Theophylline toxicity
- vomiting with GI effects
- tachycardia (restlessness, agitation, dilated pupils)
- Arrhythmias
- Convulsions
- HypoKalaemia
What medications interact with Theophylline to increase risk of hypokalaemia
- Loop/Thiazide diuretics
- Corticosteroids
- B2 Agonists
What does Ciprofloxacin and quinolones with Theophylline interaction cause
Convulsions
Quinolones lower the seizure threshold, therefore making them more likely
What medications interact with Theophylline to increase its plasma concentration and chance of toxicity
- Verapamil/CCB
- Cimetidine
- Phenytoin
- Fluconazole
- Macrolides
What medications interact with Theophylline to reduce its concentration in the blood (subtheraputic)
-St Johns wort
- Rifampicin
What to do if patient has Acute Asthma
- regard all cases as severe
- if treatment failure, transfer to hospital
Acute Asthma initial treatment
Salbutamol inhaler via large volume spacer
2-10 puffs every 10 to 20 mins or PRN
or…
Salbutamol/Terbutaline nebuliser ever 20 to 30 mins or PRN
What to do if treatment failure for acute asthma
if symptoms persist after 15 to 30 mins…
call 999
or…
repeat above and add a nebuliser ipratropium bromide
Acute asthma management after initial treatment
Prednisolone tabs or Hydrocortisone IV
Children (under 12): up to 3 days
Adult: at least 5 days (40 to 50mg once daily)
use high flow oxygen if available
What is Chronic Obstructive Pulmonary Disease (COPD)
Irreversible airway obstruction
COPD with breathlessness or exercise limitation:
1st Line
SABA or SAMA (short-acting muscarinic receptor antagonists)
COPD with >= 50% forced expiration rate
2nd Line:
LABA
then…
LABA/ICS combined inhaler
or…
LAMA
COPD with < 50% forced expiration rate
2nd Line:
LABA/ICS combined inhaler
or…
LAMA
COPD
3nd Line:
Triple therapy
LABA/ICS combination inhaler
and
LAMA
COPD 4th Line/ or unable to use inhalers:
Modified release theophylline
(Uniphyllin Continus)
COPD and chronic productive cough (what is the treatment for cough)
Mucolytic (carbocisteine)
Severe COPD with Hypoxaemia treatment
Oxygen therapy
About Oxygen therapy for COPD with Hypoxia
- 15 hours a day increases survival chance
- Must be 88 to 92% saturation
- must have O2 alert card
- If history of hypercapnic respiratory failure, must use venturi mask
Inhaled Antimuscarinics mode of action
relaxes smooth muscle of bronchi to cause bronchodilation
Short-Acting Antimuscarinic (SAMA) example and dose frequency
Ipratropium Bromide (TDS)
Long-Acting Antimuscarinic (LAMA) examples and dose frequency
- Aclidinium (Eklira)
- Glycopyronnium (Seebri Breezhaler)
- Umeclidinium (Incruse Elipta)
- Tiotropium (Spiriva Handihaler)
Take all OD
Eklira BD
Cautions with Inhaled Antimuscarinics
- Prostatic Hyperplasia (enlarged prostate gland)
- Risk of Angle-closure glaucoma
(enlarged iris blocks drainage pipe)
More Information on Antimuscarinic Angle-closure glaucoma
- Usually reported with nebulised ipratropium bromide (usually when given with salbutamol)
- must protect eyes
Side Effects of Inhaled Antimuscarinics
- Dry mouth
- Paradoxical bronchospasm
Acute COPD exacerbation treatment
- Bronchodilator nebuliser therapy (SABA, SAMA, Theophylline)
- IV Aminophylline (if poor response to nebulised bronchodilators)
- Short Course of oral prednisolone (30mg daily for 7 to 14 days)
(if increased breathlessness interferes with daily activity)
- Antibacterial Therapy
(if oddly coloured sputum)
Antihistamine mode of action
Binds to H1 receptor site to block the action of histamine
(OLD) Sedating Antihistamines examples
- Promethazine Hydrochloride (BD/TDS)
- Alimemazine
- Chlorphenamine (QDS)
- Hydroxyzine (QT prolongation)
(NEW) Non-Sedating Antihistamines examples
- Acrivastine (TDS)
- Cetirizine (OD)
- Loratidine (OD)
- Fexofenadine (OD)
Main Antihistamine Indications
- Nasal Allergies (hay fever)
- Skin Allergies (Urticaria)(Hives)
Other Antihistamine Indications
- Nausea and Vomiting
(Cyclizine and Promethazine Hydrochloride) - Insomnia
(Promethazine an Diphenhydramine) - Emergency Anaphylaxis as an adjunct
(promethazine injection)
Antihistamine lifestyle advice
- avoid alcohol
- avoid driving while on them
Antihistamine cautions
- Prostatic Hyperplasia causing urinary retention (enlarged prostate gland)
- Glaucoma (raised intraocular pressure)
- Sever Liver Impairment (sedation effect moved to liver causing hepatic coma)
Hydroxyzine (Antihistamine) cautions
- QT prolongation
- Torsade De Pointes
What is Torsade De Points
- Unique ventricular tachycardia
- QRS amplitude varies
- QRS intervals twist around baseline
Hydroxyzine (Antihistamine) use and daily dose
- Short-period use only
- Max daily dose of 100mg
Hydroxyzine (Antihistamine) contra-indications
- taking with drugs that can increase QT interval
- cardiovascular disease
- family history of sudden death
- hypokalaemia
- hypomagnesaemia
- bradycadia
What is Allergen Immunotherapy (like allergen vaccine) used for
- to reduce allergic asthma symptoms, allergic rhinoconjuctivitis
can be allergen vaccine or oral grass pollen extract.
- to reduce severe anaphylaxis in hypersensitivity to wasp and bee stings
allergen vaccines containing wasp and bee venom extract.
Allergen Immunotherapy safety concerns
- can cause a life threatening hypersensitive reaction
- needs specialist use, monitor for at least 1 hour
- Need CPR readily available
Avoid Allergen Immunotherapy in…
- Pregnant Women
- Children under 5
- Beta-blockers
- ACE Inhibitors
- Asthma (use with caution)
What is Omalizumab Injection
Monoclonal antibody that binds to IgE (Immunoglobulin E)
What is Omalizumab Injection used for
ADD on treatment
- severe persistant allergic asthma
(inadequate response to high dose ICS and LABA) - Chronic spontaneous urticaria
(inadequate response to H1 antihistamines, leukotriene receptor antagonists)
What is Chronic spontaneous urticaria
distressing skin condition that causes red, raised, itchy and sometimes painful hives or wheals (raised rash or patches) on the skin with no known obvious trigger.
Side effects of the Omalizumab Injection
- Churg-struass syndrome
(blood vessel inflammation. This inflammation can restrict blood flow to organs and tissues, sometimes permanently damaging them)
What is Anaphylaxis
an acute allergic reaction to an antigen to which the body has become hypersensitive.
What to do in case of anaphylaxis medical emergency (non-pharmacological)
- secure airways
- restore blood pressure
- raise legs and lay flat
- if sick or unconscious place in recovery position
What to do in case of anaphylaxis medical emergency (pharmacological)
Adrenaline 1 in 1000 solution
(intramuscular injection)
— INJECT IN ANTEROLATERAL ASPECT OF MIDDLE THIGH
repeat every 5 mins if necessary
give IV if compromised circulation
Anaphylaxis medical emergency Adrenaline DOSE
Child Under 6: 150mcg
Child 6 to 12: 300mcg
12 plus: 500mcg
(if child above 12 is small/pre-puberty 300mcg)
Anaphylaxis medical emergency Adrenaline Alternative
Patients on Beta-Blockers may not respond to adrenaline
treat with bronchodilator
e.g salbutamol
What is the Adjunct therapies for adrenaline in Anaphylaxis medical emergency
- high flow oxygen and IV fluids
- chlorphenamine injection
- Hydrocortisone Injection
What does a chlorphenamine injection do
counters histamine-mediated vasodilation and bronchospasm
What does a hydrocortisone injection do
prevents further deterioration in severely affected patients
Self Administration of adrenaline auto-injectors
- carry 2 at all times
- patient must be trained on how to use a particular auto-injector (practice using trainer device)
- Check expiry dates, get new ones before expiry date
What is angioedema
swelling of the skin often caused by allergic reactions
What is present with Severe angioedema and how to treat
laryngeal oedema is present in severe angioedema
- larynx area oedema
Treat with same as anaphylaxis…
- adrenaline
- antihistamine
- corticosteroid
Mucolytics mode of action
facilitates expectoration by reducing sputum viscosity
expectoration: discharge via throat/lungs via coughing and spitting
Examples of Mucolytics
- Carbocisteine
- Erdosteine
Uses of Mucloytics
reduces COPD exacerbations in patients with chronic productive cough
Mucolytic contra-indications
Active peptic ulcers
(mucolyitcs disrupt gastric mucosa)
What is cystic fibrosis
an inherited condition that causes sticky mucus to build up in the lungs and digestive system.
Cystic fibrosis 1st line treatment
- Dornase alfa 2500 units of nebulised inhalation solution once daily
- Mannitol 400mg inhalation powder twice daily
(if dornase alfa is unsuitable)
What is Dornase alfa
a genetically engineered version of a naturally occurring human enzyme which cleaves extracellular deoxyribonucleic acid (DNA).
Cystic Fibrosis 2nd Line Treatment
Sodium Chloride nebulised solution
What is CROUP (medical emergency)
Croup is a common childhood infection that causes a barking cough and a rasping sound when breathing. It’s usually mild but may need treatment.
CROUP treatment for child 1 month to 2 years
Dexamethasone oral solution
What is Idiopathic pulmonary fibrosis (IPF)
a condition in which the lungs become scarred and breathing becomes increasingly difficult.
Pharmacological Treatment of Idiopathic pulmonary fibrosis (IPF)
- Pirfenidone
- Nintedanib
Pirfenidone mode of action
slow down the process of scarring in the lungs by reducing the activity of the immune system.
Pirfenidone dose in Idiopathic pulmonary fibrosis (IPF)
1 capsule 3 times a day
Pirfenidone side effects
- feeling sick
- tiredness
- diarrhoea
- indigestion
- a rash caused by exposure to sunlight
Pirfenidone serious side effect
Serious liver damage
Liver Damage side effects
- yellowing of the eyes or skin
- loss of appetite
- itchy skin
- your pee turns a darker colour
- feeling tired
- pain in the upper right side of your stomach
Nintedanib mode of action
help slow down scarring of the lungs
Nintedanib dose in Idiopathic pulmonary fibrosis (IPF)
1 capsule twice daily
Side effects of Nintedanib
- diarrhoea
- feeling and being sick
- tummy (abdominal) pain
- loss of appetite and weight loss
