Respiratory Systems Flashcards
What kind of medication is Guaiphenesin?
Cough EXPECTORANT
These claim to make the coughing easier while enhancing production of mucus and phlegm.
Other example: Acetylcysteine, ammonium chloride
Not effective in children
What kind of medicine is Dextromethorphan?
Cough suppressant (antitussive)
What antihistamine do we usually give to children?
Chlorphenamine maleate (piriton)
Suitable for 1 year and over
What age are steroid nasal sprays e.g. beconase, flixonase, not suitable in?
Under 18’s
Is it pharmacologically rational for a cough/cold remedy to contain dextromethorphan and guanefenesin? What about dextromethorphan and ammonium chloride?
No:
Dextromethorphan is a cough suppressant so person coughing less
Guanefenesin and ammonium chloride both cough expectorants which means they make it easier to cough things up: work against each other
What is the medication causing drowsiness usually included in cough/ cough remedies to help people sleep?
Diphenhydramine
A sedating antihistamine, found in things like Night nurse.
Also found in sleep aids such as sominex
Can pseudoephidrine cause drowsniess?
Can guaifenesin cause drowsiness?
Can dextromethorphan?
No
Remember pseudoephidrine (SUDAFED) can be abused- stimulating- side effects include restlessness and insomnia, and hallucinations!
Guaifenesin does not cause drowsiness
Dextromethorphan can cause a little bit of drowsiness
Children under __ should not be given cough and cold medication OTC containing PSEUDOEPHEDRINE
PHENYLEPHRINE
DEXTROMETHORPHAN
PHOLCODINE
GUAIFENESIN
Chlorphenamine, brompheniramine, diphenhydramine, doxylamine, promethazine and triprolidine.
Children under 6 years old
Medicines containing:
ANTITUSSIVES (suppressants) (DEXTROMETHORPHAN
PHOLCODINE)
Expectorants (GUAIFENESIN, ipecacuanha)
Nasal decongestants (pseudo, phenylephrine, ephedrine, oxymetazoline, xylometazoline)
Antihistamines: Chlorphenamine, brompheniramine, diphenhydramine, doxylamine, promethazine and triprolidine.
For use in 6-12 years they should be SECOND LINE and be used for no more than 5 DAYS
A patient with a productive cough for the last week requests a product containing dextromethorphan because they have heard good things. What do you do?
They may have requested Benylin Dry Cough
Similar product: Benadril Tickly Cough containing Pholcodine
These are cough SUPPRESSANTS
Should NOT suppress a productive cough- need to get the mucous out- so recommend an expectorant (Guaiphenesin)
Why has the safety of using medicines containing codeine to treat coughs and colds in children younger than 18 been reviewed?
Because of the potential for serious problems like slowed or difficult breathing.
Children, especially those who already have breathing problems, may be more prone to these effects
Differences in metabolism of codeine: codeine is converted to Morphine in the body, this cause cause respiratory difficulties.
This use in under 18’s only applies to codeine linctus for colds/ cough; codeine containing products for pain relief can still be used in > 12 years, sold to > 16 years.
Pseudoephidrine is contra-indicated in which condition?
What about phenylephrine?
Pseudoephedrine: Hypertension, coronary artery disease, MAOI’s in the last two weeks
Phenylephrine: diabetes (as may increase glucose) and CV disease
Due to the damage influenza virus can do the airways - what complication can it lead to and in which patient groups need to be caution?
Pneumonia / pneumonitis
Very young
Elderly
Impaired immunological responses
Long term condition - heart, resp, kidney disease, diabetes
Warning signs of pneumonia complications - severe/productive cough
pleuritic pain
persisting high temp
When to refer for those with cold/flu? (7)
- Earache not improving with analgesic
- Very young
- Very old
- Long term conditions - Asthma, COPD, kidney, diabetes
- Persisting fever & productive cough
- Delirium
- Pleuritic type chest pain
OTC cough and cold medicines containing ….(4) should not be sold for under 6 years?
What about for 6- 12 year olds?
- Antitussives - dextromethorphan & pholcodine
- Expectorants - Guaifenesin & Ipecacuanha
- Nasal decongestants - Ephedrine, oxymetazoline etc
- Antihistamines - Brompheniramine, Chlorphenamine, promethazine etc
6- 12 years old can still use but for no longer than 5 days
How do nasal decongestants work and what advice should be given with their use?
Constrict blood vessels in nasal mucosa
No longer than 7 days use - rebound congestion can occur with topical but not oral decongestants
Can topical decongestants be used in 6- 12 years old?
Under 6?
6 -12 Yes
Under 6 No
Which of the topical decongestants have longer lasting effects
Oxymetazoline
Xylometazoline
upto 6 hours
compared to others such as ephedrine
In which patient groups should Ephedrine and pseudoephedrine be used with caution? & why?
(4)
- Hypertensive patients -raise BP
- Heart patients & Hyperthyroidism - stimulant effects on heart as they more vulnerable to irregularity
- Diabetics - increase blood glucose
What interactions can occur with ephedrine/pseudoephedrine?
- Monoamine oxidase inhibitors (MAOIs) - hypertensive crisis. Risk still there 2 weeks after MAOIs stopped.
Applicable to both oral and topical sympathomimetics
- Beta blockers - contradictory effect
Antihistamines can be used to reduce cold symptoms e.g. runny nose and sneezing
What are the interactions that can make side effects worse?
Cause drowsiness
- Alcohol will increase this effect
- Benzodiazepines or phenothiazines
Anticholinergic side effects (dry mouth, urinary retention, blurred vision, constipation) enhanced with other anticholinergic drugs
- Hyoscine
- Tricyclic antidepressants
- Inhaled ipratropium / tiotropium
Antihistamines should be avoided in which patient groups? (3)
- Closed angle glaucoma - increase ocular pressure
- Prostatic hypertrophy - acute urinary retention
- Epilepsy - seizures as stimulate the CNS but usually at high doses
Annual flu vaccine is available to which patient groups? (9)
- Over 65
- Chronic respiratory
- Chronic heart disease
- Chronic renal failure
- Chronic neurological disease
- Diabetes mellitus
- Immunosuppression due to treatment/disease
- Pregnant
- People living in long stay residence
Flu nasal spray available to who?
- Age 2, 3 and 4 and those in year 1, 2 and 3
2. 2-17 years at a risk due to condition e.g. diabetes
Antivirals (3) are available for seasonal flu to at risk groups under which conditions?
Neuraminidase inhibitors
Oseltamivir
Zanamivir
Amantadine
Can be used in flu outbreaks if treatment is started within
36 h for zanamivir
48 h for oseltamivir
Amantadine not usually used - lower efficacy
What is acute sinusitis ?
Treated with what?
When secretions in sinuses become stagnant with nasal secretions during/after cold.
Infected with Staphylococcus or haemophilis
Abx - amoxicillin or cefaclor if penicillin allergy
Pt’s child has persistent night time chough. What would you advise?
Referral - as could be asthma
When is a cough classed as acute or chronic?
acute - less than 3 weeks
chronic - more than 8 weeks
What is a demulcents?
Example and how they work?
Simple linctus - soothing ingredients such as glycerol or syrup
Help to supress voluntary cough mechanism - reducing frequency of cough
Honey and lemon tea
What are some ingredients (4) that are expectorants?
- Ipecacuanha
- Ammonium chloride
- Squill
- Guaifenesin
BNF - more likely placebo effect
Anti-tussives such as codeine or opioid are not recommended … why?
What can be recommended for adults instead? Why?
under 6 years - NO - risk of respiratory side effects
12 -18 with breathing problems or breastfeeding mothers
Not ideal in general - due to high incidence of side effects - constipation and dependence
Pholcodine - fewer side effects than codeine
Dextromethorphan (Benylin/Robitussin dry cough) (non-sedating opiate) and menthol shown to supress cough reflex without adverse effects of opiates.
What is croup and caused by the….?
Any treatment?
Croup - characteristic barking cough starts as a cold
causes trachea to become inflamed and swollen, thick mucus produced too
Worst in first 3 days
caused by the parainfluenza virus
No treatment as it is viral - antipyretic treatment if fever is present
No cough treatments especially those that can cause drowsiness
Parents should calm the child, sit them upright and maintain adequate fluids
Emergency/ Referral cough symptoms? (13)
999
- Stridor (abnormal high pitched musical breathing) /airway obstruction
- Difficulty breathing
- Pale/cold/clammy
- Unable to swallow saliva/fluids
- Coughing - pink (left ventricular failure) /rust (pneumonia) / dark red (carcinoma)
if bright red and one off - no need to refer - might just be forceful coughing
GP
- Cough lasting 3 weeks
- Bacterial infection - coloured sputum
- Chest pain
- Recurrent night time coughing (asthma?)
- Medicine induced - ACE inhibitors (Captopril, Ramipril, Enalapril, Lisinopril)?
- Barking cough - croup
- Fever and night sweats - TB?
- Whooping cough (pertussis)
How do ACE inhibitors cause cough?
They control break down of bradykinin and other kinins in lungs
Theophylline can be used in OTC cough remedies.
What things/drugs can increase and decrease theophylline levels?
Increase:
Enzyme inhibitors such as:
Erythromycin
Cimetidine
Decrease: Smoking Enzyme inducers: Carbamazepine Phenytoin Rifampicin
What are some side effects of theophylline? (5)
GI disturbance Nausea Palpitations Insomnia Headache
90% of sore throats are viral. 10% are bacterial - what bacteria is the cause and which age group is most likely in?
Streptococcal - children of school age
When to refer for a sore throat? (6)
- Lasting longer than 7-10 days
- Very painful with no other symptoms and no improvement in 24-48 hrs
- Difficulty swallowing
- Medication - steroid inhalers / CARBIMAZOLE (agranulocytosis - suppression of wbc in bone marrow), METHOTREXATE, AZATHIOPRINE
- White plaques on throat/mouth - indicated oral thrush)
- Red & swollen tonsils / swollen lymph glands
(usually in strep throat or glandular fever - Epstein -Barr virus a.k.a kissing disease - paracetamol/ibuprofen
How do steroid inhalers cause sore throat?
What to advise pts?
Beclometasone or budesonide - can cause hoarseness and candidal infections of mouth and throat
usually at high doses
Rinse mouth with water after using inhaler
use a spacer
Management options for sore throat?
Analgesics - paracetamol/ibuprofen / flurbiprofen lozenges (12+) / benzydamine (anti-inflammatory) spray 6+ and mouthwash 12+
Local anaesthetic -lidocaine, benzocaine sprays or lozenges
Antibiotic lozenges - Cetylpyridium
Advice on who can take and how to take flurbiprofen lozenges?
12+
Each lozenge 8.75mg - One lozenges sucked in mouth every 3-6 hrs
MAX 5 a day
Can be used for up to 3 days at a time
What are the treatment option for strep throat (once u’ve referred to GP)?
1st line - Phenoxymethylpenicillin
if allergic
Clarithromycin
Treatment for candidal pharyngitis ?
- Nystatin
if more widespread /long term: fluconazole
Drugs that cause agranulocytosis? (7)
- Captopril
- Carbimazole
- Cytotoxics - methotrexate, azathioprine
- Neuroleptics - clozapine
- Penicillamine
- Sulfasalazine
- Sulfur containing ABX - sulfonamides
What are the normal symptoms of hayfever? (4)
referral signs? (4)
- Rhinorrhorea - runny nose
- Itchy eyes & nose
- Congested nose
- Sneezing
- Wheezing
- Earache / facial pain
- Purulent conjunctivitis
- No improvement in 7 days
Treatment options for hayfever?
Antihistamines:
New - acrivastine, cetirizine, loratadine
Old - chlorphenamine, promethazine, diphenhydramine
Nasal corticosteroids 18+
Sodium cromoglicate eye drops (discard after 28 days of opening)
Oral or topical decongestants
How should the non-sedating antihistamines be taken and what age suitable?
Once a day:
Loratadine 2+
Cetirizine 6+
Three times a day
Acrivastine 12+
Sedative effects of older antihistamines can be increased by … ? (4)
- Alcohol
- Sedatives
- Hypnotics
- Anxiolytics
When should sodium cromoglicate eye drops be started to be most effective?
1 week before hay fever season likely to start
QDS
Sodium cromoglicate eye drops contain the preservative ….. and should not be used by …
Benzalkonium chloride
soft contact lens wearers - can deposit in them
What topical antihistamine is available and from what age?
Azelastine nasal spray
Begin 2-3 weeks before season
5+
What type of hypersensitivity is hay fever?
IgE mediated type 1 reaction
What are the symptoms of meningitis in infants/children?
- Excess sleepiness /irratbility
- Vomiting / feeding poorly
- Crying alot
- Soft bulging spot on head
- Being stiff/ jerky
- Purpuric rash (does NOT blanch white on pressure)
- Trouble looking at bright lights
