Respiratory Flashcards
4 courses of corticosteroid what risk of complication would patient have?
Concerns about osteoporosis
Blood sugar effects, skin thinning, psychiatric reactions, chorioretinopathy
Advantages of the inhalation route
Delivers drugs directly to the airways (target organ)
Smaller doses required (than by mouth)
Less side effects ; localised side effects rather than systemic
Pressurised metered dose inhaler (PMDI)
Patients can use easily
Difficult to use by children and elderly as you need to co-ordinate; hard hold push button
Spacer devices can be fitted to remove the need for actuation (breathing in)
Effective and convenient use for mild to moderate asthma
Breath acuated inhalers
Once you breath in - automatic release of drug
Suitable for adults and older children if they can use it effectively
Mouthpiece is bigger
Must use QVAR autohaler from the side as top has vents (dont block airflow)
Dry powder inhalers
Useful in adults and children over 5
Who are unwilling or unable to use pMDI
E.g are accuhaler
Changing from a PMDI to a DPI
Patients may notice a lack of sensation in the mouth and throat previously associated with each actuation
Coughing can occur
Advice patients to use carefully
Check technique understanding; often main cause of lack of drug response is poor technique
Spacer devices
Removes the need for coordination with PMDI
Allows larger proportion of particles to be deposited and inhaled in the lungs
Larger spaces with one way valves (volumetric) more effective than aero chambers (but their more cheaper, smaller, easy to carry and work just as well)
Not to switch between spacer devices (not interchangeable)
Caring for spacer devices
Avoid cleaning more than once a month; as electrostatic charge can affect drug delivery
Clean with mild detergent and allow to air dry without rinsing
Replace every 6-12 months
Inhale from spacer ASAP after actuation (drug aerosol very short lived)
Single dose actuation recommended
Tidal breathing (normal breaths) just as effective as single breath
Nebulisers use
Severe acute asthma
Usually given in hospital
Converts a solution of drug into an aerosol for inhalation
Used to deliver high doses of drug to the airways than with standard inhalers
Oral drugs for respiratory drug delivery
Used when inhalation not possible or more drug is required
Has more systemic side effects than inhalation
E.g B2 agonists tablets, corticosteroids, theophylline and leukotrine receptors
Parental drugs for asthma
Given by injection in severe acute asthma
Given when administration by nebulisation is inadequate or inappropriate
Arrange urgent transfer to hospital if patient treated in community
Chronic asthma
Chronic inflammation condition of the airways
Symptoms; cough, wheeze, chest tightness and breathlessness
Symptoms vary in severity and can suddenly worsen provoking asthma attack (can cause hospitalisation)
What is complete control of asthma defined as?
No day time symptoms
No night time awaking due to asthma
No attacks
No need for rescue medication
No limitation on activity including exercise
Normal lung function
Reasons for uncontrolled asthma
Lack of adherence
Suboptimal inhaler technique
Smoking; active or passive
Seasonal or environmental factors
Lifestyle changes in asthma
Weight loss to improve symptoms in overweight patients
Offer stop smoking advice and support
Offer breathing exercise programmes with drug treatmen
General advice for asthma medication
After adjusting or starting medications review response to treatment in 4-8 weeks
Adjust dose of ICS maintenance therapy over time, aiming for the lowest dose as possible to maintain effective control
Ensure patients can use device at review and when a new type of device is supplied
Management for asthma
Stepwise approach
Aim to stop symptoms
Improve peak flow
Before intimating new drug or adjusting treatment; check diagnosis, adherence / inhalation technique
Eliminate triggering factors for acute attacks
Offer personalised action plan and education to all patients with asthma
Management of asthma in adults 17 years +
1) short acting B2 agonist (SABA) e.g salbutamol and terbutaline.
If symptoms >3 weeks, waking up at night, not controlled, exacerbation in last 2 years then..
2) ADD preventer/ maintenance therapy; low dose ICS <400 mcg.
3) ADD LTRA and review in 4-8 weeks
4) ADD LABA and review to stop LTRA or not
5) SABA +/- LTRA and MART
6) increase dose ICS to 400-800, continue with MART or change to fixed dose ICS and SABA
7) increase ICS to >800
8) ADD LAMA or theophylline
Seek specialists advice
What is MART
ICS and formetrol together
Not to give SABA on its own as it already contains this
Max of 8 puffs a day
E.g Fostair
Children < 5 years
1) Offer SABA
2) 8 week trial of paediatric moderate ICS
Monitor for 8 weeks; if symptoms resolve = something else, if symptoms reoccur within 4 weeks;
2) restart ICS at a paediatric low dose
If symptoms occur beyond 4 weeks of stopping
2) repeat 8 week trial of paediatric moderate dose ICS
3) uncontrolled symptoms of paediatric low dose ICS ADD LTRA
4) if uncontrolled on paediatric low dose of ICS and LTRA, stop LTRA and refer to HCP for investigation
Management of asthma in 5-16 years
1) SABA; if short lived wheeze and normal lung function
2) ADD paediatric low dose
3) ADD LTRA and review treatment in 4-8 weeks
4) STOP LTRA and start ICS with LABA
5) change to MART regimen with low dose ICS
6) Increase ICS to moderate 200-400 with MART or change to fixed dose ICS + LABA + SABA
7) professionals advice to consider if considering increase in ICS of 400+
8) ADD theophylline
Decreasing treatment
If asthma is controlled for at least 3 months, decrease maintenance therapy
Review patients regularly when decreasing
Maintain patient at lowest possible dose of ICS
Reduce dose every 3 months by 25 to 50% each time
Reduce dose slowly as patients deteriorate at different rates
Only stop ICS completely if patients are using a paediatric or adult dose ICS alone as maintenance therapy and are symptom free.
