Victor BNF Notes > Respiratory System > Flashcards

Respiratory System Flashcards

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1
Q

What is chronic asthma

A

reversible obstructive airways

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2
Q

What are Chronic Asthma symptoms

A
  • coughing (usually at night)
  • shortness of breath
  • chest tightness
  • wheezing
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3
Q

Chronic Asthma 1st line

A

Short Acting Bronchodilators (SABA)
- Salbutamol
- Terbutaline

alternative…
- ipratropium bromeide (SAMA)
- Theophylline (if 12 or above)

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4
Q

Why move to second line in chronic asthma management

A
  • 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
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5
Q

Chronic Asthma 2nd Line

A
  • Low dose inhaled corticosteroids (BD, reduce to OD if well controlled)

(mometasone, fluticasone, beclometasone, budesonide)

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6
Q

What are alternative 2nd Line treatments for chronic asthma

A
  • inhaled sodium cromogliate
  • leukotriene receptor antagonist (montelukast)
  • Theophylline
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7
Q

Chronic Asthma 3rd Line treatment

A

Long acting Bronchodilators + Inhaled corticosteroid

LABA
- serevent
- foradil (formoterol)

Combination Inhalers with both
- Fostair
- DuoResp
- Seretide
- Symbicort

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8
Q

Chronic Asthma 4th Line treatment:
Part 1

A

If no response for 3rd Line:

Stop LABA
and…
Increase ICS dose

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9
Q

Chronic Asthma 4th Line treatment:
Part 2

A

If benefiting, but still inadequate;
continue LABA

Increase ICS dose
or…
trial LAMA (tiotropium bromide), LTRA or Theophylline

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10
Q

Chronic Asthma 5th Line treatment

A

High dose ICS + fourth drug…

  • Theophylline
  • LAMA (tiotropium bromide)
  • LTRA
  • Oral B2 agonist tablet (bambuterol)
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11
Q

Chronic Asthma 6th Line treatment

A

short dose oral corticosteroid (5 days for adult and 3 days or child 6 to 12)

for potent asthma events

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12
Q

What is a selective B2 agonist (SABA and LABA)

A

drug that causes bronchodilation of the bronchi

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13
Q

Inhaled Short-Acting B2 Agonist examples

A

Salbutamol

Terbutaline

(both QDS PRN)

3-5 hour onset

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14
Q

Inhaled Long-Acting B2 Agonist examples

A

Formoterol

Salmeterol

(both BD)

12 hour onset

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15
Q

Other Long Acting B2 Agonist examples and what are they for

A
  • Olodaterol (COPD)
  • Indacterol (COPD)
  • Vilanterol (Anoro Elipta)
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16
Q

Example of an Oral B2 agonist oral tablet

A

Bambuterol

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17
Q

When should you not initiate a LABA

A

in a patient with rapidly deteriorating asthma

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18
Q

What type of onset is Salmeterol (LABA) and what is it not for

A

Long onset + Long action

not for…
- acute asthma relief
- prevention of exercise induced asthma

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19
Q

What type of onset is Formeterol (LABA) and what is it used for

A

Short Onset + Long Action

Used as a reliever in addition as a preventer

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20
Q

Examples of Combined Inhalers and what LABA do they contain

A

Fostair, DuoResp, Symbicort, Luforbec, Trimbow

Formeterol

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21
Q

Examples of LABA inhalers

A
  • Serevent (salmeterol)
  • Foradil (formoterol), - - Striverdi (olodaterol)
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22
Q

Examples of SABA inhalers

A
  • Salamol
  • Ventolin
  • Bricanyl (terbtaline)
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23
Q

Examples of Inhaled Corticosteroid Inhalers

A

Beclometasone Inhaler brands
- QVAR
- Beconase
- Clenil Modulite
- Kelhale
- Soprobec

Mometasone Inhaler Brands
- Nasonex
- Elocon

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24
Q

Short-Acting B2 Agonist (SABA) side effects

A
  • hand tremors
  • tachycardia
  • hyperglycaemia
  • hypokalaemia
  • Serious cardiovascular events
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25
When prescribing Inhaler always make sure to...
explicitly state dose, frequency and max puffs in 24 hours
26
What are spacers when used with inhalers
Spacers take up the medication and holds it for the patient to inhale easier
27
More information on SABA Side Effect: Hypokalaemia
Hypokalaemia can be increased via... SABA + corticosteroid / other b2 agonists / theophylline monitor serum potassium
28
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
29
Inhaled Corticosteroid (ICS) mode of action
reduces inflammation in the bronchi
30
Inhaled Corticosteroids examples and how often to take
BD dosing... - beclometasone - budesonide - fluticasone OD dosing... - ciclesonide BD an OD dosing... - mometasone
31
How to long should someone take Inhaled corticosteroids for prevention of asthma
3 - 4 weeks
32
What does CFC free mean stand for in inhalers
free from chlorofluorocarbons
33
Most potent and fine beclometasone cfc free inhalers
Least Potent/Least fine Clenil Modulite Qvar Fostair Most Potent/Most Fine
34
Qvar minimum age
12+
35
Any Easyhaler minimum age
18+
36
Inhaled Corticosteroid side effects
- hoarse voice - sore throat - oral candidiasis - paradoxical bronchospasm
37
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
38
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
39
What are the NICE guide lines on who should use large-volume spacers
- patients with high does ICS - patients under 15
40
What lifestyle activity reduces the effectiveness of ICS
Current or previous smoking may need higher dose
41
When to consider giving a patient a steroid card
if their corticosteroids dose is greater than max licensed dose
42
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
43
Examples of Leukotriene Receptor Antagonists
Montelukast Zafirlukast
44
Leukotriene Receptor Antagonists Side effects
- churg strauss syndrome (blood vessel inflammation) (cardiovascular symptoms)
45
Leukotriene Receptor Antagonists Side effects: Specifically Zafirlukast
Liver toxicity Patient Counselling: report symptoms such as: - nausea - vomiting - jaundice - abdominal pain - itching
46
Theophylline (Xanthine Bronchodilator) example
IV Aminophylline (theophylline and ethylenediamine) is 20x more soluble
47
Signs of Theophylline toxicity
- vomiting with GI effects - tachycardia (restlessness, agitation, dilated pupils) - Arrhythmias - Convulsions - HypoKalaemia
48
What medications interact with Theophylline to increase risk of hypokalaemia
- Loop/Thiazide diuretics - Corticosteroids - B2 Agonists
49
What does Ciprofloxacin and quinolones with Theophylline interaction cause
Convulsions Quinolones lower the seizure threshold, therefore making them more likely
50
What medications interact with Theophylline to increase its plasma concentration and chance of toxicity
- Verapamil/CCB - Cimetidine - Phenytoin - Fluconazole - Macrolides
51
What medications interact with Theophylline to reduce its concentration in the blood (subtheraputic)
-St Johns wort - Rifampicin
52
What to do if patient has Acute Asthma
- regard all cases as severe - if treatment failure, transfer to hospital
53
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
54
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
55
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
56
What is Chronic Obstructive Pulmonary Disease (COPD)
Irreversible airway obstruction
57
COPD with breathlessness or exercise limitation: 1st Line
SABA or SAMA (short-acting muscarinic receptor antagonists)
58
COPD with >= 50% forced expiration rate 2nd Line:
LABA then... LABA/ICS combined inhaler or... LAMA
59
COPD with < 50% forced expiration rate 2nd Line:
LABA/ICS combined inhaler or... LAMA
60
COPD 3nd Line:
Triple therapy LABA/ICS combination inhaler and LAMA
61
COPD 4th Line/ or unable to use inhalers:
Modified release theophylline (Uniphyllin Continus)
62
COPD and chronic productive cough (what is the treatment for cough)
Mucolytic (carbocisteine)
63
Severe COPD with Hypoxaemia treatment
Oxygen therapy
64
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
65
Inhaled Antimuscarinics mode of action
relaxes smooth muscle of bronchi to cause bronchodilation
66
Short-Acting Antimuscarinic (SAMA) example and dose frequency
Ipratropium Bromide (TDS)
67
Long-Acting Antimuscarinic (LAMA) examples and dose frequency
- Aclidinium (Eklira) - Glycopyronnium (Seebri Breezhaler) - Umeclidinium (Incruse Elipta) - Tiotropium (Spiriva Handihaler) Take all OD Eklira BD
68
Cautions with Inhaled Antimuscarinics
- Prostatic Hyperplasia (enlarged prostate gland) - Risk of Angle-closure glaucoma (enlarged iris blocks drainage pipe)
69
More Information on Antimuscarinic Angle-closure glaucoma
- Usually reported with nebulised ipratropium bromide (usually when given with salbutamol) - must protect eyes
70
Side Effects of Inhaled Antimuscarinics
- Dry mouth - Paradoxical bronchospasm
71
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)
72
Antihistamine mode of action
Binds to H1 receptor site to block the action of histamine
73
(OLD) Sedating Antihistamines examples
- Promethazine Hydrochloride (BD/TDS) - Alimemazine - Chlorphenamine (QDS) - Hydroxyzine (QT prolongation)
74
(NEW) Non-Sedating Antihistamines examples
- Acrivastine (TDS) - Cetirizine (OD) - Loratidine (OD) - Fexofenadine (OD)
75
Main Antihistamine Indications
- Nasal Allergies (hay fever) - Skin Allergies (Urticaria)(Hives)
76
Other Antihistamine Indications
- Nausea and Vomiting (Cyclizine and Promethazine Hydrochloride) - Insomnia (Promethazine an Diphenhydramine) - Emergency Anaphylaxis as an adjunct (promethazine injection)
77
Antihistamine lifestyle advice
- avoid alcohol - avoid driving while on them
78
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)
79
Hydroxyzine (Antihistamine) cautions
- QT prolongation - Torsade De Pointes
80
What is Torsade De Points
- Unique ventricular tachycardia - QRS amplitude varies - QRS intervals twist around baseline
81
Hydroxyzine (Antihistamine) use and daily dose
- Short-period use only - Max daily dose of 100mg
82
Hydroxyzine (Antihistamine) contra-indications
- taking with drugs that can increase QT interval - cardiovascular disease - family history of sudden death - hypokalaemia - hypomagnesaemia - bradycadia
83
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.
84
Allergen Immunotherapy safety concerns
- can cause a life threatening hypersensitive reaction - needs specialist use, monitor for at least 1 hour - Need CPR readily available
85
Avoid Allergen Immunotherapy in...
- Pregnant Women - Children under 5 - Beta-blockers - ACE Inhibitors - Asthma (use with caution)
86
What is Omalizumab Injection
Monoclonal antibody that binds to IgE (Immunoglobulin E)
87
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)
88
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.
89
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)
90
What is Anaphylaxis
an acute allergic reaction to an antigen to which the body has become hypersensitive.
91
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
92
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
93
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)
94
Anaphylaxis medical emergency Adrenaline Alternative
Patients on Beta-Blockers may not respond to adrenaline treat with bronchodilator e.g salbutamol
95
What is the Adjunct therapies for adrenaline in Anaphylaxis medical emergency
- high flow oxygen and IV fluids - chlorphenamine injection - Hydrocortisone Injection
96
What does a chlorphenamine injection do
counters histamine-mediated vasodilation and bronchospasm
97
What does a hydrocortisone injection do
prevents further deterioration in severely affected patients
98
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
99
What is angioedema
swelling of the skin often caused by allergic reactions
100
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
101
Mucolytics mode of action
facilitates expectoration by reducing sputum viscosity expectoration: discharge via throat/lungs via coughing and spitting
102
Examples of Mucolytics
- Carbocisteine - Erdosteine
103
Uses of Mucloytics
reduces COPD exacerbations in patients with chronic productive cough
104
Mucolytic contra-indications
Active peptic ulcers (mucolyitcs disrupt gastric mucosa)
105
What is cystic fibrosis
an inherited condition that causes sticky mucus to build up in the lungs and digestive system.
106
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)
107
What is Dornase alfa
a genetically engineered version of a naturally occurring human enzyme which cleaves extracellular deoxyribonucleic acid (DNA).
108
Cystic Fibrosis 2nd Line Treatment
Sodium Chloride nebulised solution
109
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.
110
CROUP treatment for child 1 month to 2 years
Dexamethasone oral solution
111
What is Idiopathic pulmonary fibrosis (IPF)
a condition in which the lungs become scarred and breathing becomes increasingly difficult.
112
Pharmacological Treatment of Idiopathic pulmonary fibrosis (IPF)
- Pirfenidone - Nintedanib
113
Pirfenidone mode of action
slow down the process of scarring in the lungs by reducing the activity of the immune system.
114
Pirfenidone dose in Idiopathic pulmonary fibrosis (IPF)
1 capsule 3 times a day
115
Pirfenidone side effects
- feeling sick - tiredness - diarrhoea - indigestion - a rash caused by exposure to sunlight
116
Pirfenidone serious side effect
Serious liver damage
117
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
118
Nintedanib mode of action
help slow down scarring of the lungs
119
Nintedanib dose in Idiopathic pulmonary fibrosis (IPF)
1 capsule twice daily
120
Side effects of Nintedanib
- diarrhoea - feeling and being sick - tummy (abdominal) pain - loss of appetite and weight loss
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