Respiratory System, Drug Delivery

Question 1

________________ delivers the drug directly to the airways; the dose required is smaller than when given by mouth and side-effects are reduced

Answer 1

Inhalation

Question 2

Inhaler devices include … (3)

Answer 2

1. Pressurized metered-dose inhalers
2. Breath-actuated inhalers
3. Dry powder inhalers

Question 3

____________ can help patients, particularly the elderly and children, use pressurized metered-dose inhalers because they remove the need to coordinate actuation with inhalation

Answer 3

Spacer devices

Question 4

_____________ inhalers may be useful in adults and children over 5 years who are unwilling or unable to use a pressurised metered-dose inhaler.

Answer 4

Dry powder

Question 5

Alternatively, ______________ inhalers are suitable for adults and older children provided they can use the device effectively

Answer 5

breath-actuated

*Consider the patient’s preference when testing alternative devices to a pressurised metered-dose inhaler; there is no evidence to dictate an order in which devices should be tested

Question 6

A spacer should always be used if the patient is on a high dose of _____________

Answer 6

inhaled corticosteroid

Question 7

In adults with mild or moderate acute asthma attacks, a pressurised metered-dose inhaler with a spacer is at least as effective as _____________

Answer 7

nebulisation

Question 8

On changing from a pressurised metered-dose inhaler to a dry powder inhaler, patients may notice a _______________ previously associated with each actuation. Coughing may also occur

Answer 8

lack of sensation in the mouth and throat

Question 9

The patient should be instructed carefully on the use of the inhaler. It is important to check that the inhaler continues to be used correctly because inadequate inhalation technique may be mistaken for a ______________

Answer 9

lack of response to the drug

Question 10

The number and different types of inhalers given to a patient should be _____________

Answer 10

minimised

Question 11

To avoid accidental aspiration of loose objects when using a pressurized metered dose inhaler, patients should be advised to carry out the following steps… (4)

Answer 11

1. Remove mouthpiece cover fully
2. Shake device
3. Check both the outside and inside of the mouthpiece are clear and undamaged before inhaling dose
4. Store the inhaler with the mouthpiece cover on

Question 12

The spacer device reduces the _____________ of the aerosol and subsequent impaction on the oropharynx and allows more time for evaporation of the __________ so that a larger proportion of the particles can be inhaled and deposited in the lungs

Answer 12

velocity

propellant

Question 13

Spacer devices are particularly useful for which patients? (5)

Answer 13

1. Patients with poor inhalation technique
2. Children
3. Patients requiring high doses of ICS
4. Nocturnal asthma
5. Patients prone to candidiasis with ICS

Question 14

Patients should inhale from the spacer device ________________ after actuation because the drug aerosol is very short-lived

Answer 14

as soon as possible

Question 15

True or False: when using a spacer, patients should take a single deep breath to maximize absorption of the drug into their lungs

Answer 15

False; tidal breathing is as effective as single breaths

Question 16

How often should spacers be cleaned?

Answer 16

Once a month by washing in mild detergent; should be allowed to air-dry without rinsing

Question 17

Why should frequent cleaning of the spacer be avoided?

Answer 17

Electrostatic charge may affect drug delivery

Question 18

How often should spacer devices be replaced?

Answer 18

Every 6-12 months

Question 19

Solutions for nebulisation used in severe or life-threatening asthma attacks are administered over _________ minutes from a nebuliser, usually driven by oxygen

Answer 19

5–10

Question 20

Patients with a severe attack of asthma should preferably have oxygen during nebulisation since beta2 agonists can increase ________________

Answer 20

arterial hypoxaemia

• However, the absence of supplemental oxygen should not delay treatment

Question 21

A nebuliser converts a ___________ of a drug into an ___________ for inhalation.

Answer 21

solution

aerosol

Question 22

What are the main drugs delivered by nebulizer? (6)

Answer 22

1. Beta 2 agonist
2. Ipratropium bromide
3. Corticosteroid eg budesonide
4. Antibiotic eg colistimethate sodium or pentamidine
5. Mucolytic
6. Adrenaline

Question 23

What are the clinical indications of nebulizers? (5)

Answer 23

1. Acute exacerbation of asthma or COPD (SABA or ipratropium bromide)
2. Regular treatment of severe asthma or reversible airway obstruction when the patient is unable to use other devices (SABA, ipratropium bromide, or steroids)
3. CF (colistimethate or mucolytics)
4. Severe croup (budesonide or adrenaline)
5. Prophylaxis or treatment of PJP (pentamidine)

Question 24

Before prescribing a nebuliser, a home trial should preferably be undertaken to monitor response for up to ___ weeks on standard treatment and up to ___ weeks on nebulised treatment

Answer 24

2

2

Question 25

If prescribed a nebulizer, patients must have clear instructions from a doctor, specialist nurse, physiotherapist, or pharmacist on the use of the nebuliser (including maintenance and cleaning) and on _______________

Answer 25

peak-flow monitoring

Question 26

If prescribed a nebulizer, patients must be instructed not to ______________
have regular follow up by a doctor, specialist nurse or physiotherapist after about 1 month and annually thereafter.

Answer 26

treat acute attacks at home without also seeking help

Question 27

If prescribed a nebulizer, patients must have regular follow up by a doctor, specialist nurse or physiotherapist after about _____________ and ______________ thereafter.

Answer 27

1 month

annually

Question 28

The proportion of a nebuliser solution that reaches the lungs depends on the type of nebuliser and although it can be as high as _____%, it is more frequently close to ____% and sometimes below 10%

Answer 28

30

10

• The remaining solution is left in the nebuliser as residual volume or is deposited in the mouthpiece and tubing

Question 29

The extent to which the nebulised solution is deposited in the airways or alveoli depends on the _____________, _____________, and ____________

Answer 29

droplet size

pattern of breath inhalation

condition of the lung

Question 30

Droplets with a mass median diameter of ________ microns are deposited in the airways and are therefore appropriate for asthma, whereas a particle size of _________ microns is needed for alveolar deposition of pentamidine isetionate to combat pneumocystis infection

Answer 30

1–5

1–2

• The type of nebuliser is therefore chosen according to the deposition required and according to the viscosity of the solution.

Question 31

Jet nebulisers are more widely used than ultrasonic nebulisers. Most jet nebulisers require an optimum gas flow rate of ________ litres/minute and in hospital can be driven by piped air or oxygen

Answer 31

6–8

• Domiciliary oxygen cylinders do not provide an adequate flow rate, therefore an electrical compressor is required for domiciliary use

Question 32

For patients at risk of ___________, such as those with chronic obstructive pulmonary disease, oxygen can be dangerous and the nebuliser should be driven by air

Answer 32

hypercapnia

*If oxygen is required, it should be given simultaneously by nasal cannula

Question 33

Ultrasonic nebulisers produce an aerosol by ultrasonic vibration of the drug solution and therefore do not require a gas flow; they are not suitable for the nebulisation of some drugs, such as ____________ and nebulised suspensions.

Answer 33

dornase alfa

Question 34

Ultrasonic nebulisers produce an aerosol by ultrasonic __________ of the drug solution and therefore do not require a _________; they are not suitable for the nebulisation of some drugs, such as dornase alfa and nebulised suspensions.

Answer 34

vibration

gas flow

Question 35

Nebulisation may be carried out using an undiluted nebuliser solution or it may require dilution beforehand. The usual diluent is ______________

Answer 35

sterile sodium chloride 0.9% (physiological saline)

Question 36

The oral route is used when administration by inhalation is not possible. ______________ occur more frequently when a drug is given orally rather than by inhalation

Answer 36

Systemic side-effects

Question 37

Drugs given by mouth for the treatment of asthma include _______________, _______________, and ______________

Answer 37

corticosteroids (though also given via inhalation)

Theophylline

LTRAs

Question 38

Drugs such as _____________, _____________, and _____________ can be given by injection in severe acute and life-threatening asthma when administration by nebulisation is inadequate or inappropriate

Answer 38

beta2 agonists

corticosteroids

aminophylline (contains theophylline)

Question 39

When used in addition to symptom-based monitoring, peak flow monitoring has not been proven to improve asthma control in either adults or children, however measurement of peak flow may be of benefit in adult patients who are ‘_____________’ and hence _________________, and for those with more severe asthma

Answer 39

poor perceivers

slow to detect deterioration in their asthma

Question 40

When peak flow meters are used, patients must be given clear guidelines as to the ____________________

Answer 40

action they should take if their peak flow falls below a certain level

*Patients can also be encouraged to adjust some of their own treatment (within specified limits) according to changes in peak flow rate