Respiratory v2 Flashcards
A 41-year-old female with a recent asthma diagnosis presents with a prescription for Atrovent (ipratropium) 20mcg/dose CFC-free inhaler and Salamol (salbutamol) 100mcg/dose CFC-free inhaler. She is also prescribed Amitriptyline 10mg tablets for neuropathic pain and takes chlorphenamine 4mg tablets daily for hay fever during the summer. Which of the following side effects is this patient most likely to experience?
Choose only ONE best answer.
A
Paraesthesia
B
Myalgia
C
Dry mouth
D
Abdominal pain
E
Diarrhoea
C – Dry mouth is a common or very common side effect reported with ipratropium, amitriptyline and chlorphenamine, this due to the anticholinergic properties of these medications.
A 23-year-old patient arrives at the pharmacy experiencing difficulty breathing. They are struggling to speak in full sentences and inform you that they left their blue inhaler at home. You respond by providing an emergency supply of a salbutamol inhaler along with a spacer. What is the correct dosage of Salbutamol for the patient to administer?
Choose only ONE best answer.
A
4 puffs initially, followed by 2 puffs every 1 minutes according to response, up to 8 puffs
B
4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs
C
2 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs
D
4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 12 puffs
E
6 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs
B – If a nebuliser is not available the recommended dose for an adult is 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs
You are a rotational pharmacist on a 4-month placement in the respiratory ward. A 10-year-old patient with a history of asthma was admitted last night due to worsening symptoms despite using their salbutamol inhaler. His SpO2 was 91% on admission. The attending doctor administered salbutamol and oxygen which helped control the symptoms. Which other medication must be prescribed in all cases of acute asthma?
Choose only ONE best answer.
A
Ipratropium bromide
B
Magnesium sulphate
C
Tiotropium bromide
D
Prednisolone
E
Terbutaline
D – Prednisolone, as the patient has already been given initial treatment with a beta-2-agonist and oxygen therefore the next step in therapy is a corticosteroid. An adequate dose of prednisolone should be prescribed in all cases of acute asthma.
A 7-year-old girl is coming in for a medication review. She is currently using a salbutamol 100mcg inhaler and a Clenil 50mcg inhaler. The patient demonstrates effective inhaler technique and reports being adherent. Despite this, she remains symptomatic, which affects her daily activities. What would be the best next step in treatment for this patient?
Choose only ONE best answer.
A
Add on montelukast
B
Add on zafirlukast
C
Add on formoterol / beclomethasone
D
Switch to formoterol / beclomethasone maintenance and reliever therapy
E
Switch to salbutamol / beclomethasone maintenance and reliever therapy
D – In patients aged 5-11 years old, if their asthma is not controlled using a twice daily ICS and when required SABA, you would switch them over to a maintenance and reliever therapy of an ICS and formoterol. If a MART regimen cannot be managed, you would add on the formoterol and ICS combination as a twice daily reliever therapy, whilst also using the SABA when required.
While studying respiratory conditions, you encounter a section listing medications that should be prescribed by brand name, including theophylline. What is the reason for this requirement?
Choose only ONE best answer.
A
Cost
B
Adherence
C
Bioavailability
D
Mechanism of action
E
Pharmacodynamic properties
C – The rate of absorption from modified-release theophylline preparations can differ between brands. If a prescription does not specify a brand name, the pharmacist should contact the prescriber to confirm which brand should be dispensed.
Spacers are tube-like devices that connect to inhalers, assisting in the effective delivery of medication. Which of the following patients would NOT benefit from using a spacer?
Choose only ONE best answer.
A
A 4-year-old child recently diagnosed with asthma
B
A 81-year-old diagnosed with asthma in 1982
C
A 52-year-old with poor inhalation technique needing to use a pMDI
D
A 42-year-old with high-dose inhaled corticosteroid therapy
E
A 53-year-old with poor inhalation technique needing to use a DPI
E– Spacers cannot be used with dry powder inhalers (DPIs), as they are only effective for pressurised metered dose inhalers (pMDI).
You are performing a medication review on a 19-year-old asthmatic patient and initial information gathered suggests a poor control of his asthma. Patient is prescribed salbutamol 100mcg/dose inhaler and beclomethasone 200mcg/dose inhaler as Clenil brand. His last medication review was in 2020. He uses his salbutamol as and when he needs it, whilst beclomethasone he uses as 2 puffs twice a day regularly. Which of the following advice would be inappropriate to offer this patient?
Choose only ONE best answer.
A
Offer an emergency steroid card
B
Advise that changes in voice are a potential side effect of beclomethasone
C
Advise that some people may experience sudden shortness of breath known as paradoxical bronchospasms
D
Advise that using a spacer will help prevent sore throat
E
Advise that overusing his steroid inhaler can lead to palpitations and tremor
E – Option E refers to his salbutamol which when overused can cause tremor, palpitations, and arrhythmias. All other options are true.
A 29-year-old male has been diagnosed with asthma and has been prescribed beclometasone metered dose inhaler. He has been used his inhaler daily alongside a spacer and has seen much improvement in his symptoms. Which of the following is NOT classed as complete control of asthma?
Choose only ONE best answer.
A
No daytime symptoms
B
No need for rescue medication
C
Peak expiratory flow (PEF) > 80% predicted or best
D
No limitations on activity including exercise
E
No side-effects from treatment
E – According to NICE complete control of asthma can be achieved if patient experiences no daytime symptoms, no night-time awakening due to asthma, no asthma attacks, no need for rescue medication, no limitations on activity including exercise, normal lung function (in practical terms forced expiratory volume in 1 second (FEV1) and/or peak expiratory flow (PEF) > 80% predicted or best), and minimal side-effects from treatment.
As you are clinically checking prescriptions in the pharmacy you notice that one of the Drs at the practice keeps on prescribing beclomethasone generically without specifying a brand. You decide to approach him with the prescription to explain that he needs to always prescribe beclomethasone as a brand. He is quite surprised to hear this when you tell him, and asks you on the reason. Why does beclomethasone need to be prescribed as brand?
Choose only ONE best answer.
A
Clenil and Kelhale brands are twice as potent as traditional inhalers due to their extra-fine particles
B
QVAR and Kelhale brands are twice as potent as traditional inhalers due to their extra-fine particles
C
QVAR and Kelhale brands are ten times as potent as traditional inhalers due to their extra-fine particles
D
Soprobec and Clenil brands are twice as potent as traditional inhalers due to their extra-fine particles
E
QVAR and Soprobec are three time as potent as traditional inhalers due to their extra-fine particles
B – Beclomethasone dipropionate CFC-free pressurised metered-dose inhalers (Qvar and Clenil Modulite) are not interchangeable and should be prescribed by brand name. Qvar and Kelhale contain extra-fine particles, making them more potent than traditional beclomethasone dipropionate CFC-containing inhalers and approximately twice as potent as Clenil.
Master Klen Il comes to the pharmacy with his parents and a prescription for prednisolone 5mg soluble tablets, prescribed at a dose of 2mg/kg due to a severe asthma episode. His mother is asking how long he will need to take this medication. What is the maximum duration for which oral prednisolone should be administered to children after an asthma exacerbation?
Choose only ONE best answer.
A
2 days
B
3 days
C
5 days
D
7 days
E
14 days
B – For all cases of acute asthma, children should be prescribed an appropriate dose of oral prednisolone. Typically, a treatment duration of up to 3 days is adequate.
has a known history of COPD. She has been contacting her GP practice a lot more in the past few months due to increasing shortness of breath, fatigue, and chesty cough. She recently started on a course or oral amoxicillin which helped clear the sputum however symptoms remain variable and worsen especially in the evenings. She is currently using Atrovent (ipratropium bromide) 20mcg/dose inhaler CFC free and demonstrated a good inhaler technique. According to NICE guidelines, what would be the most appropriate treatment option for this patient?
Choose only ONE best answer.
A
Salmeterol
B
Terbutaline and budesonide
C
Roflumilast
D
Azithromycin and salbutamol
E
Formoterol and beclometasone
E – Patient is showing asthmatic features due to variability, and has already tried ipratropium bromide (a SAMA, a short-acting muscarinic antagonist) therefore it is suitable to intensify treatment with a LABA (long-acting beta agonist, like formoterol) and an ICS (inhaled corticosteroid like beclometasone).
A 60-year-old patient with chronic COPD has recently had a review with the respiratory nurse specialist. He successfully quit smoking four years ago when he was first diagnosed and completed pulmonary rehab at that time. He is also up to date with all require vaccinations. Over the past 12 months, he has experienced two exacerbations and is now being considered for a ‘rescue’ pack to keep at home to help prevent future hospital admissions. He is well controlled on his therapy and is aware of the symptoms that would indicate the need to start the rescue pack. What is typically included in a rescue pack?
Choose only ONE best answer.
A
Prednisolone 40mg daily and doxycycline 200mg stat, then 100mg once daily, both for a total of 7 days
B
Prednisolone 40mg daily and levofloxacin 500mg twice daily for 5 days
C
Prednisolone 30mg daily for 14 days
D
Prednisolone 30mg daily and doxycycline 200mg stat, then 100mg once daily, both for a total of 5 days
E
Prednisolone 30mg daily and levofloxacin 500mg twice daily for 7 days
D - Rescue packs typically include a course of corticosteroids and antibiotics for home use as part of a self-management strategy. The corticosteroid is usually prednisolone as the corticosteroid of choice, whilst the choice of antibiotic should ideally be based on the last sputum result, if available. Common options are amoxicillin, doxycycline, or clarithromycin
A 4-year-old child is admitted to the hospital with worsening asthma symptoms. Initial treatment with salbutamol via spacer was ineffective in relieving his symptoms. Despite being started on a course of soluble prednisolone, the child remains breathless and has difficulty completing sentences. His respiratory rate is 32 breaths per minute, and his heart rate is 140 beats per minute. His oxygen saturation is at 94% currently. Which additional treatment should be administered to provide further bronchodilation for this patient?
Choose only ONE best answer.
A
Beclomethasone dipropionate
B
Tiotropium bromide
C
Olodaterol
D
Ipratropium bromide
E
Montelukast
D – Ipratropium bromide can be added to salbutamol if the response is insufficient, as it offers greater bronchodilation.
A mother brings her 4-year-old daughter to see you. The child has a family history of atopy and has experienced wheezing with multiple viral infections. She continues to have a cough that worsens at night and during physical activity at school, requiring her to stop. Initially, she showed improvement with as-needed salbutamol and Clenil (beclometasone) 100 micrograms, two puffs twice daily. However, her symptoms have returned over the past 2-3 months despite good adherence to her preventer therapy. What would be the next line treatment for this patient?
Choose only ONE best answer.
A
Increase Clenil (beclometasone) to 1000mcg daily to be inhaled in two divided doses
B
Recommend montelukast 4mg oral granules, dose to be taken in the evening
C
Recommend amoxicillin 125mg three times a day for at least 5 days
D
Recommend dexamethasone 0.15mg/kg as a one-off dose
E
Recommend Fostair 100/6 (beclometasone/formoterol) – one puffs to be inhaled twice a day
B – Montelukast is the next treatment option according to the 2024 NICE/BTS/SIGN guidelines in children under 5 after a short-acting beta agonist and a low-dose inhaled corticosteroid result ineffective in preventing symptoms.
Whilst you are clinically checking prescriptions at your regular pharmacy, you come across a prescription which involves theophylline. You can see that the same patient also takes amisulpride 100mg tablets, furosemide 40mg tablets, felodipine 5mg tablets, azithromycin 250mg tablets, and carbamazepine 200mg M/R tablets. Which of the following medications do NOT interact with theophylline?
Choose only ONE best answer.
A
Amisulpride
B
Furosemide
C
Felodipine
D
Azithromycin
E
Carbamazepine
C – Felodipine does not interact with theophylline. However, both amisulpride and furosemide can increase the risk of hypokalaemia. Azithromycin can elevate the levels of theophylline, while carbamazepine can decrease its exposure, potentially reducing its effectiveness.
ou are a pharmacist independent prescriber working in general practice. A 62-year-old female patient attends your respiratory clinic with recent exacerbation that led her to be hospitalised and an FEV1 of less than 49%. The patient has a history of COPD, and currently uses a Fostair (beclomethasone, formoterol) 100/6 microgram pressurised meter dose inhaler. Using this resource what other treatment would you recommend for this patient?
Choose only ONE best answer.
A
Stop Fostair inhaler and start Spiriva (tiotropium) inhaler therapy
B
Add Eklira Genuair (aclidinium)
C
Switch to Seretide (salmeterol, fluticasone propionate)
D
Add roflumilast
E
Add azithromycin
B – The patient requires a combination of LABA, LAMA, and ICS. Since she is already using a combined LABA/ICS inhaler, with her current therapy you could consider adding a LAMA inhaler, like aclidinium bromide.
You are working in a busy community pharmacy when a customer with a known history of asthma requests to speak with you. Her symptoms have been well controlled for the past year, and she wants to know if it is possible to discontinue her inhalers completely. How should her therapy be reduced, and over what timeframe would it be safe to do so?
Choose only ONE best answer.
A
Consider a reduction of 10% - 25% if asthma has been controlled for at least 3 months
B
Consider a reduction of 10% - 25% if asthma has been controlled for at least 6 months
C
Consider a reduction of 25% - 50% if asthma has been controlled for at least 3 months
D
Consider a reduction of 25% - 50% if asthma has been controlled for at least 6 months
E
Consider a reduction of 25% - 50% if asthma has been controlled for at least 12 months
C - Reductions in therapy should be considered every three months, with a decrease of approximately 25–50% each time. The choice of which medication to reduce first, and by how much, should consider asthma severity, side effects, duration on the current dose, treatment benefits, and patient preference.
mother rushed into the pharmacy with her 4-year-old son, who has a history of peanut allergy. She had just applied Naseptin (chlorhexidine, neomycin) nasal cream to him, and his face is now swollen, and he appears to be in respiratory distress.Which of the following is NOT required in the management of anaphylaxis?
Choose only ONE best answer.
A
Inject adrenaline into muscle
B
Call 999
C
Sit the child upright
D
Remove trigger from device
E
Use autoinjector immediately
C – At first sign of anaphylaxis the person should lie down and raise legs, this helps the blood flow back to the heart and vital organs. Options A,B,D and E are all correct.
Spacer devices are very useful for younger children and individuals who require high doses of inhaled corticosteroids. There are specific requirements to how spacers should be cleaned and stored. How should you clean and store your spacer to ensure it remains effective and in good condition?
Choose only ONE best answer.
A
Clean the spacer with boiling water at least once a week, scrub the inside to ensure it is clean, and store it in a plastic bag to keep it dust-free
B
Clean the spacer with warm water and detergent at least once a month, avoid scrubbing the inside, air-dry it, and store it in a plastic-free sealed bag away from dust and liquids
C
Clean the spacer with cold water and detergent at least once a month, avoid scrubbing the inside, air-dry it, and store it in a plastic sealed bag away from dust and liquids
D
Clean the spacer in the dishwasher every 6-12 months, use a cloth to dry it, and store it in a plastic bag to avoid static build-up
E
Rinse the spacer with cold water at least once a month, dry it with a towel, and keep it in an open bag to ensure it stays dust-free
B
A 17-year-old female with cystic fibrosis comes to the pharmacy for a routine check-up. She reports a 4-week history of chesty cough with green, purulent sputum, and sputum tests identified Pseudomonas aeruginosa as the cause. Despite a course of antibiotics, she feels her sputum remains thick, and sodium chloride has not been effective in loosening the mucus. What would be the first-line treatment to help with her symptoms?
Choose only ONE best answer.
A
Aztreonam
B
Ivacaftor
C
Mannitol
D
Dornase alfa
E
Lumacaftor
D – For cystic fibrosis with lung disease, dornase alfa is the first-choice mucolytic. If response is inadequate, use dornase alfa with hypertonic sodium chloride or hypertonic sodium chloride alone. Mannitol is a second-line option.
