Treatments W1-4 Flashcards
Asthma first line
Short acting b2 agonists (PRN) and inhaled corticosteroids (BDS)
Examples of SABAS
Salbutamol and terbutaline
Examples of ICS
Beclometasone, budesonide, fluticasone propionate, fluticasone furoate
Second line treatment asthma
SABA, ICS and LABA - fixed dose or MART
Examples of LABAS
Salmeterol and formoterol
Third line asthma
Consider increasing ICS to medium dose or adding a LTRA. If no response to LABA consider stopping
Monoclonal antibodies in asthma MOA
Eg, omalizumab. Binds to IgE inhibiting it’s action
When monoclonal antibodies are used
When high dose ICS and LABA don’t work. Used by specialists.
When are oral steroids used in asthma
To control exacerbations of asthma
Examples of leukotriene receptor antagonists
Montelukast and zafirlukast
Bronchitis
Adequate analgesia and hydration. ABx not usually required, if necessary, amoxicillin or doxycycline
Bronchiolitis
helping baby to sleep - raising head with pillow, hydration. Supplementary oxygen and fluids if hospitalised
SABA MOA
Activate beta2-adrenergic receptors on airway smooth muscle - increases cAMP. cAMP activates protein kinase A - inhibits phosphorylation of myosin and lowers calcium concentrations. Relaxing smooth muscle.
LABA MOA
Stimulates intracellular adenyl cyclase - catalyses production of ATP –> cAMP. Increased cAMP relaxes smooth muscle and inhibits release of histamine and leukotrines.
Ultra-long B2 agonists
Antagonist of muscarinic receptors M1, M3 and M5. Inhibition of M3 receptor in smooth muscle of the lungs leads to relaxation and bronchodilation
Corticosteroids MOA in asthma: beclometasone, budesonide, fluticasone, propionate..
Inhibit leukocyte infiltration at site of inflammation and suppress humeral responses. Increase anti-inflammatory mediators. Reduce eosinophils, macrophages, lympophocytes.
Corticosteroids MOA in asthma: umeclidinium bromide and vilanterol
Stimulates adenyl cyclase - increases cAMP. Causes relaxation of smooth muscle and inhibits release of inflammatory mediators - histamine and leukotrienes
Anti-leukotrienes - Montelukast MOA
Leukotriene receptor antagonists – prevents release of inflammatory mediators and pro-inflammatory cells
Anti-leukotrienes - Zileuton MOA
Lipoxygenase inhibitors - Inhibits augmentation of neutrophil and eosinophil migration, neutrophil and monocyte aggregation, leukocyte adhesion, increased capillary permeability, and smooth muscle contraction by blocking synthesis of leukotrienes.
Monoclonal antibodies MOA
Inhibits the binding of IgE to the high-affinity IgE receptor on the surface of mast cells and basophils. The reduction in surface-bound IgE reduces release of mediators - histamine. Reduces availability of circulating IgE for binding.
What is a MART - maintenance and reliever therapy
A combined LABA and corticosteroid - way of ensuring that the improved symptom control brought about by use of LABA does not result in the neglect of inhaled corticosteroid.
Example of MART
Symbicort - formoterol LABA and Budesonide ICS
Fostair MART components
beclometasone (ICS) and formoterol (LABA)
Relvar MART components
fluticasone duroate (ICS) and vilanterol (LABA)
Management of associated problems with asthma - gastroesophageal reflux disease
PPI - omeprazole
Management of associated problems with asthma - allergic rhinitis
Nasal corticosteroids
COPD ongoing treatment
SMOKING CESSATION. Patient education and vaccination. Try and manage symptoms with bronchodilators - short or long acting, corticosteroid, anticholinergics, pulmonary rehabilitation, LTOT
Surgical interventions for COPD
bullectomy (removal of large air sacs from destroyed alveoli), lung volume reduction surgery (remove diseased portions of lung so healthier parts can function better), endobronchial valves, transplantation
What is an endobronchial valve
One-way valve inserted into a bronchiole - air can flow out of valve during exhalation, but not in during inhalation. Aids expiration in areas of lung where there is hyperinflation due to lack of elasticity - emphysema. When an emphysematous area of lung delates and collapses, there is more room for healthier lung to expand.
Mild chest wall abnormality management
physical therapy - exercises can improve posture and ability of chest to expand
Severe chest wall abnormality management
Cosmetic surgery to rebuild chest
Acute exacerbation of IPF
High-dose cotricosteroid (prednisolone) + or - cytotoxic therapy
Ongoing treatment of IPF
antifibrotics, smoking cessation, oxygen therapy, + pulmonary rehabilitation, those with GORF PPI, lung transplant
Anti-fibrotic examples
pirfenidone or nintedanib
Non-specific interstitial pneumonia
Many respond to corticosteroids with or without immunosuppressants
Cryptogenic organising pneumonia - rare and not associated with smoking
Corticosteroids - relapse may occur if dose lowered
Desquamative interstitial pneumonia - vast majority heavy smokers
Cessation of smoking and corticosteroids
Occupational asthma
Identify and remove cause. Protective devices. Standard management of asthma to reduce symptoms
Berylliosis - beryllium - causes non ceasating granulomas
Prednisolone. Oxygen therapy, pul rehabilitation
Chronic silicosis (silicon dioxide dust inhalation)
smoking C, removal of exposure. Cough medicine, bronchodilators, and oxygen therapy if needed
Siderosis (iron and oxides inhalation)
removal of exposure, manage symptoms
Acute silicosis
Lung lavage
Coal workers lung
remove exposure. manage symptoms - oxygen therapy, bronchodilators..
Asbestosis
supportive care, pulmonary rehabilitation, +/- oxygen therapy. End stage - transplants
What does pulmonary rehabilitation include
Exercise training for endurance and muscle strength, nutritional counselling (loosing weight), education about disease and management, techniques to save energy, breathing strategies (maximising oxygen intake), counselling
Acute sarcoidosis
Prednisolone, for low o2 sats <88% ventilatory support and oxygen
Chronic sarcoidosis
- Prednisolone 2.+cytotoxics (methotrexate) and oxygen (low sats) 3. lung transplant
Hypersensitivity pneumonitis
identification and avoidance of antigen, acute - corticosteroids, chronic - ongoing low dose corticosteroids
Type 1 respiratory failure
High flow O2 (35-60%) via facemask, if PO2 remains 60% consider assisted ventilation. Target 94-100%. Manage underlying condition
Type 2 respiratory failure
O2 therapy - start at 24%, check PaCo2 if stable increase oxygen, non-invasive (positive pressure) ventilation. Target 88-94%. Manage underlying condition
When long-term oxygen therapy is introduced
COPD with PaO2 <7.3 when breathing in state of clinical stability. COPD with PaO2 7.3-8 with presence of secondary diseases (peripheral oedema, polycythaemia..). Severe chronic asthma PaO2<7.3. Interstitial lung disease PaO2<8. Pts with PaO2 8 disabling dyspnoea.
Spontaneous pneumothorax bilateral with perfusion failure (haemodynamically unstable)
Chest drain
PrimaryPTX - 2cm and/or breathless
Aspirate. Unsuccessful - chest drain.
PrimaryPTX - less than 2cm and not breathless
Discharge - review in two-four weeks
SecondaryPTX - >2cm or breathless
Chest drain
SPTX - size 1-2cm
Aspirate. Unsuccessful - chest drain
SPTX - size <1cm and not breathless
Admit. High slow oxygen observe for 24 hours
Pulmonary embolism
Begin LMWheparin. Once diagnosis confirmed, begin warfarin (takes 48 hours to have anticoag effect so continue heparin for this time). INR is measured - dose adjusted to keep it within 2-3. Warfarin treatment continued 3-6months after 1st episode
Drugs that enhance the action of warfarin
NSAIDS - aspirin. Erythromycin
Drugs that reduce the action of warfarin
carbamazepine (anti-convulsant) and barbituates
Acute massive PE in haemodynamic collapse
Thrombolytic therapy -
DVT
Elasticated compression stockings, leg exercises. Prophylactic low dose heparin.
Malignancy related pleural effusions
Management of underlying tumour, drainage will solve dyspnoea, pleurodesis
Infection related pleural effusion
early chest drain - ABx for infection - beware risk of empyema
Empyema
culture results pending - empirical ABx cefuroxime or ceftriaxone AND metronidazole or clindamycin
Specific ABx when known chest drain
Severe empyema doesn’t respond to ABx or chest drain
video-assisted thoracoscopic surgery. ~30% require surgery.
