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Flashcards in Asthma guidance & drugs Deck (53)
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1
Q

How should patients used DPI inhalers?

A

Need to breathe in fast and strong to create enough turbulence to lift the particles

2
Q

Why should Beclometasone CFC-free MDIs (QVAR and CLENIL) have their brand endorsed on prescriptions?

What is the combination inhaler also effected by this?

A

Because they are not interchangeable:
QVAR has extra fine particles that can reach the lungs faster and quicker therefore its more potent (QVAR is 2 x as potent as Clenil)

FOSTAIR also effected- beclometasone and formeterol - its the same as QVAR- has extra fine particles so more potent

3
Q

Which beta blockers would we be most worried about in asthmatic patients? (5)

A

Non-cardioselective beta blockers, as these may be more likely to constrict airways:

Propranolol
Sotolol
Labetolol
Carvedilol
Timolol

The cardioselective ones (atenolol, bisoprolol) are less of a worry

4
Q

How should a spacer be cleaned?

A

Wash it in mild detergent and allow to air dry, wipe mouthpiece free of detergent
Do this once a month (more frequently will effect the electrostatic charge)

5
Q

How often should a spacer be replaced?

A

Every 6-12 months

6
Q

When would nebuliser adrenaline or budesonide be needed?

A

Child with severe croup

Not severe: oral beclometasone or prednisolone usually used

7
Q

When should nebulisers be considered in long term management of COPD or asthma?

A

Remains breathless after two weeks of correctly using optimal therapy

8
Q

What proportion of nebulised drug will reach lungs?

A

10-30%

Diluent usually used in nebulisers: NaCl 0.9%

9
Q

What ages are spacers recommended in children?

A

Up till the age of 5 for bronchodilators (saba, labas)

Ages 5-15 for ICS

10
Q

What is the standard length of treatment with steroids for an asthma attack?
Does this differ in children?

A

Prednisolone oral for 5 days in adult

Prednisolone oral for 3 days in child

IF NBM- IV hydrocortisone every 6 hours until conversion to oral

Can usually abruptly stop the steroid unless the patient has been on oral corticosteroids previously (step 5) for over three weeks

11
Q

What degree of asthma attack should we consider the use of high flow oxygen?

A

If it’s severe

We use SABA (e.g. Salbutamol) nebs plus high flow oxygen

Only Saba nebs needed if moderate

12
Q

If oxygen, SABA and prednisolone are not sufficient for an asthma attack what can be considered?

A

Ipratropium bromide
IV aminophylline
Magnesium sulphate

If an attack is LIFE-THREATENING: immediately give ipratropium (don’t wait to see if response is poor as with severe asthma attacks)

13
Q

Which patients are most likely to benefit from an aminophylline infusion in an asthma attack?

A

Those that have been taking theophylline oral

14
Q

What is step 1 of the Asthma guidelines

When should a patient be moved on to step 2?

A

SABA PRN

SABAs used: salbutamol or Terbutaline

Move up if needed more than TWICE a week or woken up once per week

15
Q

What is step 2 of the asthma guidelines ?

A

SABA PRN + standard dose of ICS

Recommended starting dose for adults:
400mcg beclometasone daily
Do not go over 800 mcg daily

Max of 2 drugs permitted at step 2

16
Q

What is step 3 of the asthma guidelines? (Hint: 3 different steps involved)

A

1) Firstly add in a LABA (salmeterol, formoterol) to the ICS + PRN SABA
2) After addition of LABA can increase ICS dose to 800mcg daily (NB: this is not max dose, just upper end of standard dose range)

If above not worked:
3) stop LABA if no benefit, continue if some benefit

IF LABA STOPPED Consider adding:
Leukotriene receptor agonist (montelukast)
Theophylline MR
Oral MR beta agonists (e.g. Salbutamol tablets/ solution) do not use this in under 12 years

Max of 3 different drugs permitted at this stage

17
Q

Step 4 of the asthma treatment guidelines? (4 drugs)

A

The patient will already be on:
SABA PRN + regular standard dose ICS
LABA

1) increase ICS to a over standard dose = regular high dose ICS

Add in a 6 week trial of one or more of:
Leukotriene receptor antagonist (montelukast)
MR theophylline
Oral MR oral beta agonist

Patient on at least 4 drugs at step 4

18
Q

Step 5 of the asthma treatment guidelines? What 5 different drugs will the patient be on?

A

Add in regular corticosteroid tablets (prednisolone) refer to a respiratory specialist

Patient will be on:
PRN SABA
Regular high dose ICS
LABA
One or more of the leukotriene antagonists, theophylline MR, MR oral beta agonist
Regular prednisolone
19
Q

Stepping down: How often should asthma treatment be reviewed?

A

Every 3 months

Consider reducing by up to 50% every 3 months

20
Q

What age of child do the asthma guidelines become different?

A

Age 5

21
Q

Child under 5: asthma guidelines step 1?

A

SABA PRN

Consider moving to step 2 if child needs SABA more than twice per week, is woken at night once a week or had an exacerbation in last 2 years (same as adult guidance)

22
Q

Child under 5: asthma guidelines step 2?

A
SABA PRN
Plus standard dose regular ICS
OR MONTELUKAST (leukotriene receptor antag)
23
Q

Child under 5: asthma guidelines step 3?

A

If under 2 years old REFER to specialist

SABA PRN
Plus regular standard dose ICS
Plus montelukast

24
Q

Child under 5: asthma guidelines step 4?

A

Refer to specialist

25
Q

What is standard dose ICS for adults?

A

Equivalent to beclometasone 400-800 mcg daily (200-400mcg BD)

26
Q

What is standard dose ICS for children aged under 12?

A

200-400 mcg beclometasone daily

100-200mcg BD

27
Q

What is high dose ICS for adults?

A

800-2000mcg daily (400-1000 mcg BD)

28
Q

What is high dose ICS in children? What age range can high dose be used in?

A

400-800mcg beclometasone daily

Can only be used in 5-12 years (under 5 years cannot receive high dose ICS)

29
Q

Which ICS is not recommend in children under 12?

A

Mometasone

30
Q

What ORAL drugs used in asthma can be taken as normal in pregnancy and breast feeding? (2)

A

Prednisolone
Theophylline

NB: all inhaled drugs can be taken as normal too, where possible use inhaled therapy over oral therapy

31
Q

What oxygen level are we aiming for when oxygen is given in acute exacerbation of asthma?

A

94 - 98%

Remember it is lower in COPD (88-92%) due to risk of T2 respiratory failure/ higher levels of CO2 in blood

32
Q

What are the two SABAs that are used at step 1 of asthma treatment?

A

Salbutamol

Terbutaline

33
Q

Should LABAs be used for the relief for exercise induced asthma symptoms?

A

No unless regular ICS also used

34
Q

Which LABAs are only licensed for COPD (i.e. not also in asthma)?

A

Indacterol and Olodaterol

35
Q

What electrolyte disturbance can result from theophylline and salbutamol use together?

A

Hypokaleamia

36
Q

In management of acute exacerbations of asthma, which is

used out of aminophylline and theophylline?

A

Aminophylline

This is just the injectable form of theophylline (it consistS of theophylline plus ethylenediamine) which is 20 times more soluble (and therefore potent) than theophylline

Theophylline levels are monitored with aminophylline therapy

37
Q

What is paradoxical bronchospasm a side effect of? (This is sudden constriction of the airways)

A

Inhaled corticosteroids

It can be prevented by using a SABA beforehand or using a DPI instead

38
Q

How long does it take to see improvement with ICS?

A

3 - 7 days

39
Q

What does SMART stand for?

What does this mean?
What inhalers are involved?

A

Symbicort Preventer and reliever therapy

Symbicort contains bother a preventer (budesonide) and a reliever (formeterol)

It is supposed to take away the need for PRN reliever- salbutamol- as you instead use this as the reliever at an increased dose if you get symptoms of breathlessness

Other examples of smart inhalers:
Duoresp spiromax (also budesonide and formoterol)
Fostair (beclometasone and formoterol)

40
Q

What age group can use the SMART regime?

A

Adults and children aged 12-18 years

Children just to used symbicort

41
Q

How does smoking effect ICS?

A

Current or previous smoking reduces the effect of ICS (as smoking is an enzyme inducer) and higher doses may be needed

This is also the case with COC’s! and theophylline

42
Q

Who are leukotriene receptor antagonists more effective in?

A

Exercise induced asthma
Those with rhinitis
Used in children under 5 at step 2 onwards

43
Q

When should Montelukast be given?

A

In the evening

44
Q

What needs to be looked out for with the use of Leukotriene receptor antagonists (Montelukast + Zafirlukast)?

A

Churg-strauss syndrome
= autoimmune causing inflammation of small and medium-sized blood vessels

Look out for esonophillia, rash, worsening pulmonary symptoms, cardiac complications, peripheral neuropathy

45
Q

Zafirlukast is cautioned in ______ disorder

A

Hepatic disorders

46
Q

What are sodium chromoglycate and nedocromil used in?

A

Allergic asthma
Inhaled drugs

caution: these can cause paradoxical bronchospasm

47
Q

What is Omalizumab used in?

A

It is a monoclonal antibody that binds to immunoglobulin E

Used for sensitivity to inhaled allergens/ allergic asthma

Churd-strauss syndrome also been associated with this drug

48
Q

What 3 conditions can effect plasma theophylline concentration?

A

Heart failure
Hepatic impairment
Viral infections!

49
Q

What electrolyte disturbance can aminophylline and theophylline cause?

A

Hypokaleamia

50
Q

What is the target level of theophylline?

A

10 - 20 mg/ L

51
Q

What should be monitored when giving IV Beta 2 agonists (IV salbutamol)?

A

K+ in severe asthma

Blood glucose in diabetics as can cause hyperglycaemia and DKA!!!!

52
Q

What is the dose of salbutamol inhaler in asthma?

A

100- 200 mcg (1-2 puffs) up to 4 times a day for persistent symptoms (max 8 puffs a day)

53
Q

What are the symptoms of Oral thrush (caused by ICS)?

A

white patches (plaques) in the mouth that can often be wiped off, leaving behind red areas that may bleed slightly
loss of taste/ unpleasant taste
redness inside the mouth
cracks at the corners of the mouth
a painful, burning sensation in the mouth

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