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Pre-Reg November Exam '24 > Respiratory- MEDIUM > Flashcards

Respiratory- MEDIUM Flashcards

1
Q

What is asthma?

A

A chronic inflammatory disorder of the airways

An exaggerated bronchoconstrictor response to a wide variety of exogenous and endogenous stimuli

Recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early morning

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2
Q

What are the treatment options for asthma?

A
  • Beta 2 agonists
  • Antimuscarinics
  • Theophylline
  • Corticosteroids
  • Cromoglicate
  • Leukotriene antagonists
  • Omalizumab
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3
Q

When is oral route for asthma considered for use?

Why is inhaled preferred?

A

When inhalation is not possible

Preferred because:
* Drug delivered directly to lungs (avoids first pass metabolism)
* Smaller dose required than with oral admin.
* Fewer S/E than with oral admin.

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4
Q

What is the treatment pathway for asthma?

A
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5
Q

What is COPD?

A

Chronic Obstructive Pulmonary Disorder (COPD)

  • Airflow limitation, not fully reversible
  • Usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases
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6
Q

Who should be considered for COPD spirometry testing?

A

People over 35, current or ex-smokers, and have a chronic cough

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7
Q

How is COPD diagnosed?

A
  • The Medical Research Council dyspnoea scale graded breathlessness
  • Post-bronchodilator spirometry to confirm diagnosis
  • Chest radiograph to exclude other pathologies
  • FBC to identify anaemia or polycythaemia
  • BMI calculated
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8
Q

What are the main points of COPD treatment?

A
  • Smoking cessation!!
  • Vaccinate against infection- can complicate COPD
  • Pulmonary rehabilitation, if indicated
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9
Q

What is the treatment pathway for COPD?

A
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10
Q

When should LAMA+LABA or LABA+ICS be offered to patients?

A
  • Have spirometry confirmed COPD
    AND
  • Do not have asthmatic features
    AND
  • Remain breathless or have exacerbations despite treatment for tobacco dependence, relevant vaccinations and use of a short acting bronchodilator
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11
Q

When should LAMA+LABA+ICS be considered for patients already taking LABA+ICS?

A
  • Those who’s symptoms continue to adversely impact their quality of life or have a severe exacerbation (requiring hospitalisation)
    OR
  • Have 2 moderate exacerbations within a year
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12
Q

When should LAMA+LABA+ICS be considered for patients already taking LABA+LAMA?

A

*Those having a severe exacerbation (requiring hospitalisation)
OR
*They have 2 moderate exacerbations within a year

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13
Q

What is the advice surrounding oral corticosteroid use in COPD?

A

*Long-term use is not normally recommended
* Those with advanced COPD may need long-term oral corticosteroids, but the dose should be kept as low as possible

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14
Q

What is a spirometry test?

A

Tests how an individual inhales or exhales volumes of air as a function of time

The primary signal measured in spirometry may be volume or flow

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15
Q

Define Forced Vital Capacity (FVC)

A

Forced Vital Capacity (FVC)- the maximal volume of air exhaled with maximally forced effort from a maximal inspiration

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16
Q

Define FEV1

A

Forced Expired Volume in one second (FEV1)- volume expired in the first second of maximal expiration after a maximal inspiration

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17
Q

What is FEV1/FVC

A

FEV1 expressed as a percentage of the FVC, gives a clinically useful index of airflow limitation

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18
Q

What is a clinically healthy FEV1/FVC?

And that of airflow limitation?

A

Healthy = 70-80%

Limited airflow = < 70%

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19
Q

What are the benefits of spacers for inhalers?

A
  • Suitable for children and elderly who find pMDIs difficult
  • Reduces aerosol velocity, gives more time for evaporation of propellant therefore, larger proportion of particles reach target
  • Useful for high dose ICS and patients prone to candidiasis (thrush)
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20
Q

Points to consider for spacers?

A
  • Size of spacer is very important, as well as size of face mask (if using)
  • Replace spacer every 6-12 months
  • Clean once monthly with mild detergent, air dry
  • Inhale from spacer asap after activation as aerosol is short-lived
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21
Q

What is the mode of action of sympathomimetics?

A
  • Relax airway smooth muscle
  • Inhibit mediator release
  • Increase ciliary activity

Examples:
* Epinephrine (adrenaline)
* Isoprenaline (isoproterenol)
* β2 selective agents

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22
Q

What is formoterol (Oxis, flutiformm symbicort)
typically indicated for?

A
  • Chronic asthma
  • Exercise-induced bronchospasm
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23
Q

What is indacterol (Onbrez) indicated for?

A

COPD

  • Improves the ability of patients with COPD to exercise
  • Ultra-long acting and fast onset of action
  • As effective as tiotropium bromide
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24
Q

What is salbutamol (Salamol, Ventolin) indicated for?

A

Asthma and other conditions associated with reversible airways obstruction

Rapid onset of action; drug of choice as relief for symptoms of bronchospasm

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25
Q

What is salmeterol (Severent) indicated for?

A
  • Prophylaxis of bronchospasm
  • NOT for acute attacks, has long onset of action
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26
Q

What is terbutaline (Bricanyl) indicated for?

A
  • Treatment of asthma and other conditions associated with reversible airways obstruction
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27
Q

What is the mode of action of beta-2 agonists?

A

Act directly on Beta-2 receptors, causing smooth muscle relaxation and dilation of the airways

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28
Q

What are the common S/E for Beta-2 agonists?

A
  • Palpitations (less common with non-selective; vasodilation and reflex tachycardia; direct stimulation of β-2 in the heart)
  • Hypokalaemia (K+ in skeletal muscle and in serum; tolerance)
  • Fine tremor of skeletal muscle (hands)
  • Nervousness, sleep disturbances
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29
Q

Where do Beta-2 agonists need to be used in caution?

A
  • Hyperthyroidism
    *CVD (HTN, arrhythmias, susceptibility to QT prolongation)
    Diabetes (risk of ketoacidosis- glycogenesis in liver)
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30
Q

What is the mode of action of adrenaline (epinepherine)?

A
  • Effective and rapidly acting bronchodilator (inh/SC)
  • Simulates Beta-1+2 receptors (non-selective)
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31
Q

Common S/E of adrenaline?

A
  • Tachycardia
  • Arrhythmia
  • Dry mouth
  • Insomnia
  • Restlessness
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32
Q

What are adrenaline’s uses in emergencies?

A
  • Acute allergic reactions (anaphylaxis)
  • Angioedema
  • Management of severe croup (RTS- seal coughing in children)
  • Cardiopulmonary resuscitation
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33
Q

What is the mode of action of antimuscarinic bronchodilators?

A
  • Reduce vagal cholinergic tone, the main reversible component of COPD
  • Inhibit the effect of acetylcholine at muscarinic receptors
  • Block contraction of airway smooth muscle
  • Block the secretion of mucus
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34
Q

Give an example of a naturally occurring antimuscarinic

A

Atropine

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35
Q

Give examples of synthetic antimuscarinics

A
  • Ipratropium bromide
  • Oxitropium bromide
  • Tiotropium bromide
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36
Q

When should antimuscarinic therapy be used in caution?

A
  • Glaucoma
  • Prostatic hyperplasia
  • Bladder outflow obstruction
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37
Q

What is ipratropium indicated for?

A
  • Short term relief in chronic asthma (SABA preferred)
    Can be added if asthma fails to improve with standard therapy
  • Short-term relief in COPD (if not on LAMA)

Onset is 15-30 mins
Maximum effect is 60-90 mins after admin. (COPD)

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38
Q

What is aclidinium (Eklira) indicated for?

A

Maintenance for COPD (not suitable for acute bronchospasm)

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39
Q

What is glycopyronium bromide (Seebri) indicated for?

A

Maintenance therapy for COPD and hyperhidrosis (excessive sweating)

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40
Q

What is tiotropium (Spiriva) indicated for?

Dosing regimen?

A
  • COPD maintenance- 18mcg OD
  • Once daily dosing
  • Maximum effect 90-120 mins after inhalation

Spiriva RESPIMAT restricted for use in COPD for patients with poor manual dexterity

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41
Q

What are the common S/E for tiotropium?

A
  • Dry mouth
  • GI motility (diarrhoea, constipation)
  • Cough
  • Nausea
  • Angle closure glaucoma
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42
Q

Under what class does Theophylline fall under?

What do these class of med do?
Any downsides?

A

Xanthines

  • Have bronchodilator and anti-inflammatory effects
  • β2 agonists are more effective as bronchodilators and corticosteroids have greater anti-inflammatory effect
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43
Q

Points to consider for theophylline therapy?

A
  • Despite extensive use in respiratory disease, molecular action not fully understood
  • Metabolised by CYP450
  • Has a very narrow therapeutic window (requires close monitoring)
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44
Q

What is the effective therapeutic window for theophylline?

A

Plasma conc. : 10-20 mg/L

Doses must be adjusted in individual patients according to their their plasma concentration

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45
Q

What are the monitoring requirements for theophylline?

A

Plasma concentration

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46
Q

What can cause increases plasma concentrations of theophylline?

A
  • Heart failure
  • Hepatic impairment
  • Viral infection
  • Elderly
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47
Q

What can cause a decrease in plasma concentrations of theophylline?

A
  • Smokers
  • Alcohol consumption
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48
Q

Does prescribing need to be by brand on theophylline?

What is the most common brand?

A

Yes- the rate of release from MR preps varies

If no brand mentioned on Rx- contact prescriber

Most common- Uniphyllin Continus

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49
Q

What is the MAX dosing for theophylline?

A

400mg 12-hourly

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50
Q

What are the S/E associated with theophylline?

A
  • CNS: increased alertness, insomnia, tremor, headache
  • CVD: inotropic and chronotropic positive effects tachycardia
  • GI: stimulates gastric acid secretion, anorexia, nausea, vomiting, gastro-oesophageal reflux
  • Kidney: diuretic
  • Smooth muscle: Bronchodilation
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51
Q

What decreases the metabolism of theophylline?

and therefore increases serum concentration

A
  • Old age
  • Arterial hypoxemia (low oxygen sat.)
  • Respiratory acidosis
  • Congestive cardiac failure
  • Liver cirrhosis
  • Erythromycin
  • Quinolone antibiotics
  • Cimetidine (NOT ranitidine)
  • Viral infections
  • Herbal remedies (St. John’s Wort)
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52
Q

What increases the metabolism of theophylline?

and therefore decreases serum concentration

A
  • Tobacco smoking
  • Alcohol
  • Anticonvulsant drugs
  • Rifampicin
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53
Q

What is aminophylline?

Differences to theophylline?

A

Theophylline + ethylenediamine

  • Given by very slow IV infusion
  • Too irritant for IM use, 20x more soluble than theophylline
54
Q

Does branded prescribing need to take place?

A

Yes- MR preps vary in rate of release

55
Q

When should phylloctonin continus forte tablets (aminophylline) be used?

A

In patients where theophylline has a shorter half life

56
Q

What is the most common compound bronchodilator preparation?

What is it indicated for?

A

Combivent: 500mcg
* Ipratropium + 2.5mg salbutamol

Indicated for bronchospasm in COPD

57
Q

When and why is use of compound bronchodilator therapy used?

A

When patients are stable on both constituent drugs

Used because it is best to treat with single drug- can adjust dose more easily

58
Q

What is the benefit of nebulisers?

A

Delivers a greater proportion of the drug to the lungs compared with standard inhalers

59
Q

When should nebulisers be used with caution?

A
  • Acute angle-closure glaucoma associated with nebulised drugs i.e. ipratropium
  • NB: eye care during nebulisation
60
Q

What are nebulisers indicated for?

A
  • Beta-2 agonist or ipratropium in acute exacerbation asthma
  • Beta-2 agonist, corticosteroids ipratropium in severe asthma
  • Antibiotic or mucolytic in cystic fibrosis
  • Budesonide or adrenaline to child with severe croup
  • Pentamidine for treatment/prophylaxis of pneumocystis pneumonia
61
Q

What is the mode of action of corticosteroids?

More specifically in respiratory care?

A
  • Once in the cell they bind to specific receptors in the cytoplasm- ‘activated glucocorticoid-receptor complex’ translocates to the nucleus to interact with the DNA
  • This induces transcription of particular genes and synthesis of some proteins and vice versa

In respiratory care:
* Transcription of various pro-inflammatory gene products are modified
* This reduces airway inflammation and hyper responsiveness

62
Q

How are inhaled corticosteroids (ICS) used in asthma?

Effects of regular ICS use?

A
  • They reduce airway inflammation, oedema and secretion of mucus
  • ICS used prophylactically if Beta-2 agonist required > 2 weeks, or if sleep disturbances or exacerbations in last 2 years requiring systemic CS
  • Regular use reduces risk of exacerbation
  • Smoking reduces effectiveness of CS
63
Q

How are ICS used in COPD?

A

CS reduce exacerbations when combined with LABA

64
Q

What can high doses of ICS lead to?

A
  • Adrenal suppression
  • Associated with pneumonia in elderly with COPD
65
Q

What can long-term treatment with ICS leads to?

A

Reduced bone mineral density, predisposes to osteoporosis

Height of children on prolonged treatment should be monitored

66
Q

What are the common S/E of ICS?

A
  • Hoarseness, dysphagia, throat irritation, oropharyngeal candidiasis
  • Hyperglycaemia with high doses
  • Anxiety, depression, sleep disturbances
67
Q

How can patients manage oral candidiasis?

A
  • Reduce risk by using spacer and rinsing mouth/ brushing teeth after use
  • Antifungal oral gel can be used to treat OTC without stopping treatment
68
Q

Give 5 examples of ICSs

A
  • Beclomethasone (Becotide)
  • Budesonide (Pulmicort)
  • Fluticasone (Flixotide)
  • Mometasone (Asmanex)
  • triamcinolone (Nasacort)
69
Q

What are the systemic S/E associated with long-term, high dose treatment with ICS?

A
  • Skin thinning, easy bruising
  • Glaucoma, cataracts
  • Adrenal suppression
  • Slow growth rate in children
  • Low bone mineral density –> osteoporosis
70
Q

How does poorly controlled asthma affect a foetus during pregnancy?

A
  • Low birth weight
  • Increased perinatal mortality
  • Prematurity
  • Risk of foetal hypoxia
71
Q

How are acute exacerbations controlled in asthmatic pregnant patients?

A
  • SABA- nebulised
  • Oxygen
  • Systemic glucocorticoid therapy, when necessary
72
Q

What is the mode of action of leukotriene receptor antagonists?

A
  • Block effect of cysteinel leukotrienes on airway
  • Improve lung function and reduce asthma exacerbations
73
Q

What are the effects of leukotrienes?

A
  • Increase in microvascular permeability (oedema)
  • Increased mucus secretion
  • involved in smooth muscle proliferation and remodelling
  • Increased infiltration of eosinophils into airways
74
Q

What are the side effects associated with leukotriene receptor antagonists?

A
  • Churg Strauss Syndrome
  • GI upset
  • Headache
75
Q

Give an example of a leukotriene receptor antagonists and its dosing regimen

A

Montelukast- 10mg at night
5mg at night for child < 15 y/o

76
Q

What is Churg Strauss Syndrome?

How can it be spotted?

A

An autoimmune disorder marked by blood vessel inflammation (vasculitis)

Monitor for signs of eosinophilia, vascularitic rash, peripheral neuropathy and cardiac complications

77
Q

What is the mode of action of phosphodiesterase type-4 inhibitors?

A
  • Prevent activation of the intracellular cyclic adenosine monophosphate (cAMP)/ cyclic guanosine phosphodiesterase (cGMP)
  • May improve lung function, decreasing inflammation around the small airways
78
Q

What is roflumilast indicated for?

A

Adjunctive therapy to bronchodilators (severe COPD)
Has anti-inflammatory activity

79
Q

S/E associated with roflumilast?

A
  • Increased risk of psychiatric disorders: insomnia, anxiety, nervousness and depression
  • Diarrhoea, nausea, abdominal pain
  • Headache
80
Q

When is roflumilast contra-indicated?

A
  • Moderate/severe hepatic impairment
  • Immunological diseases

Not recommended if psychiatric symptoms

81
Q

When are antihistamines used in caution?

A

Epilepsy- can increase seizure susceptibility

82
Q

Where must antihistamines be avoided?

A

Patients with severe liver disease- increased risk of coma

83
Q

What is the mode of action of H1 receptor antagonists?

A

They bind competitively bind to H1 receptors present on nerve endings, smooth muscle and glandular cells

84
Q

What are H1 receptor antagonists indicated for? (5)

A
  • Allergic rhinitis/ allergic conjunctivitis
  • Urticaria (hives)
  • Drug hypersensitivity
  • Anti-emetic
  • Sedation
85
Q

S/E associated with H1 receptor antagonists? (4)

A
  • Sedation
  • Tinnitus
  • Dizziness
  • Antimuscarinic S/E e.g. dry mouth, constipation etc
86
Q

Counselling points for antihistamines?

A

Do not drive/ operate heavy machinery

87
Q

Adverse effects associated with antihistamines?

A

Children and elderly more prone to S/E

  • Drowsiness
  • Paradoxical stimulation (opposite effect of drug)
  • Headache
  • Psychomotor impairment
  • Antimuscarinic S/E (dry mouth, urinary retention, blurred vision, GI upset)
88
Q

Examples of non-sedating vs sedating antihistamines

A
89
Q

What is the principle behind allergen immunotherapy?

A

Vaccines containing allergens i.e. house dust, cat dander, can reduce asthma symptoms

Vaccines with wasp, bee venom reduce anaphylaxis

90
Q

What is Omalizumab and its mode of action?

A

a monoclonal antibody that binds to immunoglobulin E, mitigating its allergic reaction effects on the body

91
Q

What is Omalizumab indicated for?

A

Severe, persistent asthma uncontrolled with ICS

92
Q

S/E associated with Omalizumab?

A

Associated with Churg Strauss Syndrome

  • Injection side reactions
  • Rash, diarrhoea, nausea, vomiting, menorrhagia, epistaxis (nose bleed)
93
Q

How is anaphylaxis characterised, and how is it treated?

A
  • A severe, life-threatening, systematic hypersensitivity reaction
  • Rapid cardiopulmonary symptoms

Adrenaline licenced for emergency treatment of acute anaphylaxis (angioedema, cardiopulmonary resuscitation)

94
Q

How should patient-carried adrenaline pens be administered?

What are next steps should anaphylaxis not resolve?

A
  • Lie patient flat
  • Raise legs (put in recovery position if nauseous)
  • Administer adrenaline into thigh
  • Should reverse immediate symptoms associated with hypersensitivity
  • Second dose should be 5-15 mins after, if first is unsuccessful
  • Continuous respiratory deterioration requires treatment with bronchodilators i.e. inhaled, IV salbutamol, ipratropium, IV aminophylline
95
Q

What are the potential risks causing anaphylaxis reactions?

A
  • Insect stings
  • Medication (e.g. NSAIDs, vaccines, neuromuscular blockers, latex)
  • Milk, eggs, fish, shellfish, soya
  • Arachis oil, other excipients
96
Q

3 examples of adrenaline pens

A
  • Epipen
  • Anapen
  • Jext
97
Q

What are respiratory stimulants?

A

Stimulate respiratory and non-respiratory muscles (can be harmful). Only effective given IV, and have a short duration of action. Expert supervision required

98
Q

What is Doxapram HCl indicated for?

A
  • Post operative respiratory depression
  • Acute respiratory failure
99
Q

What is Caffeine citrate indicated for?

A

Neonatal apnoea (specialist supervision in hospital)

100
Q

What is the mode of action of pulmonary surfactants?

A

They reduce the surface tension at the air/water interface in the alveoli, thereby preventing collapse of these structures at end-expiration. Also enables the lung to inflate more easily, reducing workload

101
Q

What are pulmonary surfactants indicated for?

Give 2 examples of these

A

Respiratory Distress Syndrome in neonates

Examples:
* Baractant
* Poractant alfa

102
Q

How is oxygen generally indicated?

What is its mode of action?

A

For hypoxemic patients, prescribed to achieve near-normal oxygen saturation (Aim: 94-98%)

  • Increases alveolar oxygen tension
  • Reduces workload of breathing
103
Q

In which medical conditions is high conc. oxygen suitable?

A
  • Pneumonia
  • Sepsis
104
Q

Points to consider for oxygen therapy

A
  • Consider smoking cessation before starting oxygen
  • Discuss with airlines before travelling abroad
  • Concentration used depends on condition being treated
105
Q

What is the mode of action of mucolytic drugs?

Where do they need to be used in caution?

What else could be used to the same effect?

A

Facilitate expectoration of mucus by reducing sputum viscosity

They disrupt the mucosal barrier, use in caution in peptic ulcer/ history of ulcer

Steam inhalation could also be effective

106
Q

S/E associated with carbocisteine?

At what age is it licenced for?

A

GI side effects

Used from 2 years old on

107
Q

What is erdostine indicated for?

S/E?

A

Treat acute exacerbations of chronic bronchitis

GI S/Es

108
Q

What is Dornase Alfa?

It’s function and indication?

A

Genetically engineered enzyme- glycosylated recombinant human rhDNAse

Cleaves extracellular DNA

Increase lung function, used in cystic fibrosis

109
Q

How is Dornase Alfa administered, and how often?

A
  • Admin. with jet nebuliser
  • Up to BD
110
Q

What is Ivakaftor (Kalydeco) indicated for?

How is this identified?

A

Cystic fibrosis in patients with G551D mutation in CFTR gene

Genotyping method should be performed to confirm G551D mutation in at least one allele

111
Q

What are the monitoring requirements for ivakaftor?

A

LFTs prior to treatment, also be checked every 3 months during first year of treatment, then annually thereafter

112
Q

S/E associated with ivakaftor?

A
  • Abdominal pain
  • Nausea
113
Q

Dosing schedule with ivakaftor?

A

BD dosing- reduce dose if taking with “-zoles” or “-mycins”

114
Q

What is mannitol indicated for and its administration method?

A

Cystic fibrosis- non-responsive to Dornase Alfa

Administered by inhalation

115
Q

What is the mechanism of action of mannitol?

A

Not fully understood but improves mucus clearance

116
Q

What are the potential causes of a cough?

A
  • GORD
  • Chronic bronchitis
  • Rhinitis, rhinosinusitis, post natal drip syndrome
  • a S/E of ACEi!!
  • Associated with smoking, environmental causes e.g. pollution
117
Q

What are the respective lengths of acute and chronic coughs

A
  • Chronic cough- > 8 weeks
  • Acute cough- < 3 weeks
118
Q

Recommendations for acute cough management

A
  • Acute viral cough often self-limiting and doesn’t require treatment
  • Simplest and cheapest option may be ‘home remedy’ like honey and lemon
  • Opiate antitussives have significant adverse effect profiles so aren’t recommended
119
Q

Examples of expectorant cough medicines

A

Guaifenisin, ipecacuana

120
Q

Examples of suppressant cough medicines

A

Dextromethorphan, pholcodeine, codeine

121
Q

Examples of decongestant cough medicines

A

Phenylephrine, pseudoephedrine, oxymetazoline, xylometazoine

122
Q

Examples of antihistamine cough medicines

A

Chlorphenamine, diphenhydramine, doxylamine, promethazine, tripolidine

123
Q

At what age should people not be offered liquid codeine as antitussive?

A

< 18 years old

124
Q

At what age should people not be offered couh and cold remedies?

A

< 6 years old

125
Q

Give an example of a systemic nasal decongestant

A

Pseudoephedrine (Sudafed)

126
Q

Advantages and disadvantages of systemic nasal decongestants

A

Advantage- not associated with rebound congestion

Disadvantage- not as effective as local decongestant

127
Q

When does pseudoephedrine need to be used in caution?

A
  • Diabetes
  • Hypertension
  • Hyperthyroidism
  • Ischaemic heart disease
128
Q

S/E associated with pseudoephedrine

A
  • Nausea
  • Vomiting
  • Tachycardia
129
Q

Typical dosing schedule for pseudoephedrine

A

60mg TDS-QDS

130
Q

Which high risk drugs can be used in cough suppression in palliative care?

A

Methadone
* Licenced for cough in terminal illness
* Long duration of action, accumulates

Morphine
* Shorter acting

Pre-Reg November Exam '24 (10 decks)

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