BNF - Chapter 3 - Respiratory System Flashcards
(368 cards)
1
Q
Where does inhalation deliver drugs to?
A
Directly to the airways;
2
Q
Is the dose required via inhalation route more or less than when given by mouth?
A
the dose required is smaller than when given by mouth and side-effects are reduced.
3
Q
What are the three types of of inhaler devices?
A
- Pressurised metered-dose inhalers
- Breath-actuated inhalers
- Dry powder inhalers
4
Q
Why are spacer devices useful, what do they remove the need of?
A
Spacer devices remove the need to co-ordinate actuation with inhalation
5
Q
Are dry powder inhalers suitable for those under 5?
A
No
6
Q
Who are dry powder inhalers suitable or may be used for?
A
Maybe useful for adults and children over 5 years who are unwilling or unable to use a pressurised metered-dose inhaler
7
Q
Is there evidence to suggest an order in which the types of inhaler devices should be tested?
A
No
8
Q
When should a spacer be always used?
A
When the patient is on a high dose of inhaled corticosteroids
9
Q
With adults with mild or moderate acute asthma attacks, what is at least as effective as nebulisation?
A
- a pressurised metered-dose inhaler with a spacer
10
Q
When changing from a pressurised metered-dose inhaler to a dry powder inhaler, what may patients notice?
A
- A lack of sensation in the mouth and throat previously associated with each actuation.
- Coughing may also occur
11
Q
What does a spacer device do?
A
- removes the need for co-ordination between actuation of a pressurised metered-dose inhaler and inhalation.
- The spacer device reduces the velocity of the aerosol and subsequent impaction on the oropharynx and allows more time for evaporation of the propellant so that a larger proportion of the particles can be inhaled and deposited in the lungs.
12
Q
Who are spacer devices particularly useful for?
A
- Patients with poor inhalation technique
- For children
- For patients requiring high doses of inhaled corticosteroids
- for nocturnal asthma
- patients prone to candidiasis with inhaled corticosteroids
13
Q
Are spacer devices regarded as being interchangable?
A
No, patients should be advised not to witch between spacer devices
14
Q
How often and how should the spacer device be washed?
A
- Should be cleaned once a month
- by washing in mild detergent before use
- Some manufacturers recommend more frequent cleaning, but this should be avoided since any electrostatic charge may affect drug delivery
15
Q
How often should spacer devices be replaced?
A
- every 6-12 months
16
Q
When are solutions for nebulisation used?
A
- in severe or life-threatening asthma attacks
17
Q
Over how many minutes are solutions for nebulisation administered from a nebuliser?
A
Over 5 - 10 minutes and are usually driven by oxygen
18
Q
What can beta-2 agonists increase the risk of?
A
- arterial hypoxaemia
19
Q
Why should patients with a severe attack of asthma preferably have oxygen during nebulisation?
A
- Since beta2 agonists can increase arterial hypoxia.
- However, the absence of supplementary oxygen should not delay treatment
20
Q
What does a nebuliser do in terms of particle?
A
A nebuliser converts a solution of a drug into an aerosol for inhalation.
21
Q
Are higher doses of drug given via inhaler or nebuliser?
A
A nebuliser
- it is used to deliver higher doses of drug to the airways than is usual with standard inhalers.
22
Q
What are the main indications for the use of a nebuliser?
A
- a beta2 agonist or ipratropium bromide to a patient with an acute exacerbation of asthma or of COPD
- a beta2 agonist, corticosteroid, or ipratropium bromide on a regular basis to a patient with severe asthma or reversible airways obstruction when the patient is unable to use other inhalation devices;
- an antibiotic (such as colistimethate sodium) or mucolytic to a patient with cystic fibrosis
- budesonide or adrenaline/epinephrine to a child with severe croup
- petamidine isetionate for the prophylaxis and treatment of pneuocystis pneumonia
23
Q
Before prescribing a nebuliser, what should be trialed?
A
- a home trial should be undertaken to monitor response for up to 2 weeks on standard treatment and up to 2 weeks on nebulised treatment
24
Q
What proportion (percentage) of a nebuliser solution reaches the lungs?
A
- depends on the type of nebuliser and although it can be as high as 30%, it is more frequently close to 10% and sometimes below 10%.
25
If 30% of nebuliser solution or more commonly 10% of it reaches the lungs then what happens to the rest of the nebuliser solution?
- The remaining solution is left in the nebuliser as residual volume or is deposited in the mouthpiece and tubing.
26
The extent to which nebulised solution is deposited in the airways or alveoli is dependent on what?
- droplet size, pattern of breath inhalation, and condition of the lung.
27
Where are droplets with a mass median diameter of 1-5 microns depositied?
Deposited in the airways and are therefore appropriate for asthma
28
Where are particles sized 1-2 microns depostied?
- alveolar deposition
| - good for pentamidine isetionate to combat pneumocystis infection.
29
Are jet nebulisers used more widely than ultrasonic nebulisers?
Yes
30
What do most jet nebulisers require an optimum gas flow rate level of?
Flow rate of 6-8 litres/minute and in hospital can be driven by piped air or oxygen
31
In acute asthma what should the jet nebuliser be driven by?
by oxygen
32
Domicilliary oxygen cylinders do not provide an adequate flow rate therefore what should be used?
An electrical compressor is required for domicilliary use
33
What is hypercapnia?
It is a build up of carbon dioxide in the blood stream.
| it affects people who have COPD.
34
For patients at risk of hypercapnia such as those with COPD, what should the nebuliser be driven by and why?
oxygen can be dangerous and the nebuliser should be driven by air.
If oxygen is required, it should be given simultaneously by nasal cannula.
35
How do ultrasonic nebulisers work?
- Ultrasonic nebulisers produce an aerosol by ultrasonic vibration of the drug solution and therefor do not require a gas flow
- They are not suitable for the nebulisation of some drugs, such as dornase alfa and nebulised suspensions.
36
What is the usual nebuliser diluent?
Nebulisation may be carried out using an undiluted nebuliser solution or it may require dilution beforehand.
The usual diluent is sterile sodium chloride 0.9% (physiological saline).
37
In England and Wales are nebulisers and compressors available on the NHS?
nebulisers and compressors are not available on the NHS (but they are free of VAT);
38
what is the disadvantage of giving drugs orally than by inhalation?
More systemic side effects
39
Which drugs can be given by mouth for the treatment of asthma?
- Corticosteroids
- Theophylline
- Leukotriene receptor antagonists (e.g. Montelukast)
40
Which drugs can be given parenterally for asthma?
- beta 2 agonists
- Corticosteroids
- Aminophylline (can be given by injection in severe acute and life-threatening asthma when administration by nebulisation is inadequate or inappropriate).
41
Who may peak flow meters benefit?
measurement of peak flow may be of benefit in adult patients who are ‘poor perceivers’ and hence slow to detect deterioration in their asthma, and for those with more severe asthma.
42
What are the most frequent symptoms of asthma?
- Cough
- Wheeze
- Chest tightness
- Breathlessness
Asthma symptoms vary over time and in intensity and can gradually or suddenly worsen, provoking an acute asthma attack that, if severe, may require hospitalisation.
43
What is asthma- COPD overlap syndrome characterised by?
- by persistent airflow limitation displaying features of both asthma and COPD
44
What is complete control of asthma defined as?
- As having no daytime symptoms,
- No night-time awakening due to asthma,
- no asthma attacks
- no need for rescue medication
- no limitations on activity including exercise,
- Normal lung function (in practical terms forced expiratory volume in 1 second (FEV1) and or peak expiratory flow (PEF) >80% predicted or best), and minimal side effects from treatment.
45
What lifestyle changes can be promoted for chronic asthma?
- Weight loss
- smoking cessation
- breathing exercise programmes (can be offered to adults as an adjuvant to drug treatment to improve quality of life and reduce symptoms).
46
What should be offered or in place for all patients with asthma (and/ or their family or carers)?
- A self-management programme comprising of a written personalised action plan and education
- and supported with regular review by a healthcare professional
47
What ages do NICE and BTS/SIGN recommendations on adults refer to?
NICE = 17 years and over
-
BTS/SIGN = over 12 years
48
What should patients be started on for chronic asthma?
Intermittent reliever therapy
- Start an inhaled short acting beta 2 agonist (such as salbutamol or terbutaline) to be used as required in all patients with asthma.
49
Patients using more than how many short acting beta 2 agonist inhaler device a month should be urgently assessed?
more than 1 device
Patients using more than one short-acting beta2 agonist inhaler device a month should have their asthma urgently assessed and action taken to improve poorly controlled asthma.
50
What maintenance therapy should be used in control of chronic asthma?
Regular preventer (maintenance) therapy
A low dose of ICS should be started as maintenance therapy in patients who present with any one of the following features:
- using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week.
51
What frequency of administration is recommended of the reliver (maintenance) therapy?
recommend that inhaled corticosteroids (except ciclesonide) should initially be taken twice daily, however the same total daily dose taken once a day, can be considered in patients with milder disease if good or complete control of asthma is established.
52
What dose BTS/SIGN recommend in terms of prescribing inhalers?
Prescribing by brands
53
What is the initial add on therapy if asthma is uncontrolled on a low-dose of ICS as maintenance therapy?
- Add a leukotriene receptor antagonist (LTRA- such as Montelukast) as an addition to ICS, and response to treatment reviewed in 4 to 8 weeks.
54
What does BTS/SIGN recommend instead for intiial add on therapy if low-dose ICS is not adequate at controlling asthma symptoms?
- Recommend a long-acting beta2 agonsit (LABA - such as salmeterol or formoterol)
- can be given as either a fixed doe ICS and LABA regimen or a MART regimen (maintenance and reliver therapy - a combination of an ICS and a fast acting LABA such as formoterol in a single inhaler (Fostair)
55
IF asthma is uncontrolled on a low-dose of ICS and LTRA as maintenance therapy, then what should be added?
a LABA in combination with the ICS should be offered with or without continued LTRA treatment, depending on the response achieved from the LTRA
56
If asthma remains uncontrolled what should be changed/ or added?
If asthma remains uncontrolled, offer to change the ICS and LABA maintenance therapy to a MART regimen, with a low-dose of ICS as maintenance.
57
What if asthma still remains uncontrolled on MART regimen and low dose ICS?
consider increasing to a moderate-dose of ICS (either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy).
58
If asthma is still uncontrolled in patients on a moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), with or without a LTRA then what should be considered next steps?
Increasing the ICS dose to a high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist used as reliever therapy), or
A trial of an additional drug, for example, a long-acting muscarinic receptor antagonist (such as tiotropium) or modified-release theophylline, or
Seeking advice from an asthma specialist
59
Under specialist advice what further add on treatments are available?
Under specialist care, BTS/SIGN (2019) recommend that if asthma control remains inadequate on a medium-dose of ICS, plus a LABA or LTRA, the following interventions can be considered:
Increasing the ICS to a high-dose—with high doses of ICS via a pressurised metered dose inhaler (pMDI) a spacer should be used, or
Adding a LTRA (if not already tried), or modified-release theophylline, or tiotropium.
If a trial of a further add-on treatment is ineffective, stop the drug (or in the case of increased dose of ICS, reduce to the original dose).
60
Can frequent use of corticosteroids be used under specialist therapies?
Yes - recommend adding a regular oral corticosteroid (prednisolone) at the lowest dose to provide adequate control in patients with very severe asthma uncontrolled on a high-dose ICS, and who have also tried (or are still receiving) a LABA, LTRA, tiotropium, or modified-release theophylline.
61
Which monoclonal antibodies can be used in controlling severe asthma?
Under specialist initiation, BTS/SIGN (2019) recommend that monoclonal antibodies such as omalizumab (for severe persistent allergic asthma), mepolizumab, benralizumab and reslizumab (in adults for severe eosinophilic asthma), and immunosuppressants such as methotrexate [unlicensed], may be considered in patients with severe asthma to achieve control and reduce the use of oral corticosteroids
62
Which intermittent reliver therapy is recommended for children 5 years and over (5 - 16 years)?
- start an inhaled short acting beta 2 agonist (such as salbutamol or terbutaline)
63
What regular preventer (maintenance therapy) is recommended in children?
- A paediatric low dose of ICS should be started as maintenance therapy in children who present with any on e of the following;
using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week.
64
For children what is the initial add on therapy?
If asthma is uncontrolled on a paediatric low-dose of ICS as maintenance therapy, consider a leukotriene receptor antagonist (LTRA—such as montelukast) in addition to the ICS, and review the response to treatment in 4 to 8 weeks.
65
For children, like similar to adults what does BTS/SIGN recommend instead as initial add on therapy?
BTS/SIGN (2019) instead recommend a long-acting beta2 agonist (LABA—such as salmeterol or formoterol fumarate) as initial add-on therapy to low-dose ICS if asthma is uncontrolled in children aged over 12 years.
- fixed or MART combination
66
If asthma is uncontrolled in a child 5-16 years old on a paediatric low-dose of ICS and a LTRA as maintenance therapy, what should be considered
consider discontinuation of the LTRA and initiation of a LABA in combination with the ICS.
If asthma remains uncontrolled on a paediatric low-dose of ICS and a LABA as maintenance therapy, consider changing to a MART regimen (Maintenance And Reliever Therapy—a combination of an ICS and fast-acting LABA such as formoterol in a single inhaler) with a paediatric low-dose of ICS as maintenance.
67
If asthma remains uncontrolled in a child aged 5-16 on a MART regimen with a paediatric low-dose of ICS as maintenance, what should be considered next?
consider increasing to a paediatric moderate-dose of ICS (either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy).
68
If asthma is still uncontrolled in a child aged 5-16 on a paediatric moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), what should be considered next?
consider seeking advice from an asthma specialist and the following options:
Increasing the ICS dose to a paediatric high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist as reliever therapy), or
A trial of an additional drug, such as modified-release theophylline.
69
Under specialist care can an oral corticosteroid be used long term for treatment of asthma in children aged 5-16?
Under specialist care, BTS/SIGN (2019) recommend adding a regular oral corticosteroid (prednisolone) at the lowest dose to provide adequate control in children with very severe asthma uncontrolled on a high-dose ICS, and who have also tried (or are still receiving) a LABA, LTRA, tiotropium (child over 12 years), or modified-release theophylline.
70
Which children (age) can tiotropium be considered?
Over 12 years
71
Which monoclonal antibodies can be considered in children?
Under specialist initiation, BTS/SIGN (2019) recommend that monoclonal antibodies such as omalizumab (child over 6 years for severe persistent allergic asthma), and immunosuppressants such as methotrexate [unlicensed] can be considered in children with severe asthma to achieve control and reduce the use of oral corticosteroids.
72
When treating chronic asthma in children under age of 5, what intermittent reliever therapy is recommended?
- A short acting beta 2 agonist (such as salbutamol) as a reliver therapy.
73
For children under 5, for asthma what regular preventer (maintenance) therapy is recommended?
Consider an 8-week trial of a paediatric moderate-dose of ICS in children presenting with any of the following features: asthma-related symptoms three times a week or more, experiencing night-time awakening at least once a week, or suspected asthma that is uncontrolled with a short-acting beta2 agonist alone.
74
After 8 weeks of the trail of moderate ICS what should you do next for the child (under 5 years)?
After 8 weeks, stop ICS treatment and continue to monitor the child's symptoms:
If symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely;
If symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low-dose as first-line maintenance therapy;
If symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8-week trial of a paediatric moderate-dose of ICS
75
What is the initial add on therapy for treating asthma for child under 5?
If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS as maintenance therapy, consider a leukotriene receptor antagonist (LTRA—such as montelukast) in addition to the ICS.
If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS and a LTRA as maintenance therapy, stop the LTRA and refer the child to an asthma specialist.
76
After how many months of current well controlled maintenance therapy should you consider decreasing maintenance therapy?
At least three months
Furthermore, reductions should be considered every three months, decreasing the dose by approximately 25-50% each time.
77
What is exercise induced asthma a sign of?
- Poorly controlled asthma and regular treatment including ICS should therefore be reviewed.
78
If exercise is a specific problem in patients already taking an ICS who are otherwise well controlled, what should you consider adding to treatment?
consider adding either a LTRA, a long-acting beta2 agonist, sodium cromoglicate or nedocromil sodium, or theophylline
An inhaled short-acting beta2 agonist used immediately before exercise is the drug of choice.
79
Women with asthma should be closely monitored during pregnancy, true or false?
TRue
80
Which drugs can be used as normal to manage asthma in pregnant women?
Short-acting beta2 agonists, LABAs, oral and inhaled corticosteroids, sodium cromoglicate and nedocromil sodium, and oral and intravenous theophylline (with appropriate monitoring) can be used as normal during pregnancy.
81
Which drug used in asthma treatment should be used with caution or only if needed when treating pregnant women?
here is limited information on use of a LTRA during pregnancy, however, where indicated to achieve adequate control, they should not be withheld.
82
As summary of the management of Chronic Asthma (adults and children over 5 years) what is the 1st line treatment?
- Inhaled short acting beta 2 agonist (e.g. salbutamol) used as required
If patient presents with any one of the following: using inhaled beta2 agonist 3 times a week or more, being symptomatic 3 times a week or more, experiencing night-time symptoms atleast once a week or had an asthma attack in the last 2 years --- MOVE TO STEP 2
83
What is second line?
• ADD a regular inhaled standard-dose corticosteroid (e.g. Beclometasone, Budesonide, Fluticasone, Mometasone).
- Fluticasone and Mometasone provide equal clinical activity to Beclometasone and Budesonide at HALF the dosage
ICS should be taken initially TWICE daily, however the same TOTAL dose can be taken ONCE daily if good control is established
84
In children. administration of high doses of ICS may be associated with what?
- Growth failure
- Reduced bone mineral density
- adrenal suppression
85
What is third line/ step 3?
• ADD a Long-acting beta2 agonist (LABA) such as formoterol or salmeterol to be used in conjunction with the ICS.
- If the patient is gaining some benefit from addition of LABA but control is inadequate, then continue LABA and increase dose of ICS to top end of the range.
- If there is no response to the LABA, discontinue and increase dose of ICS.
- If control is still INADEQUATE, start a trial of either a leukotriene receptor antagonist (e.g. Montelukast), modified-release Theophylline, or modified-release oral beta2 agonist. Leukotriene receptor antagonists are the preferred option in children.
- Before proceeding to Step 5, refer patients with inadequately controlled asthma to specialist care
Step 3 is up until Leukotriene receptor antagonist and Theophylline.
Step 4 is modified-release oral beta2 agonist.
86
What is step 5 of chronic asthma management?
- Before proceeding to Step 5, refer patients with inadequately controlled asthma to specialist care
ADD a regular oral corticosteroid (Prednisolone as a single daily dose) at lowest dose to provide adequate control
- Continue high dose ICS
87
Summarise the treatment steps of chronic asthma in children under 5 years old?
Management of Asthma in Children under 5 years is essentially the same as with adults and children over 5:
Step 1 and 2 are the same.
But at Step 2, if child cannot take ICS, give a Leukotriene-receptor antagonist instead.
At Step 3, add a leukotriene receptor antagonist if it was not added at step 2. But if a leukotriene receptor antagonist was added, reconsider adding an ICS.
Step 4 refer child to respiratory paediatrician.
88
In pregnant women how are drugs for asthma preferred to be delivered?
Via inhalation to minimise exposure to the fetus
89
What is the drug of choice for exercise-induced asthma?
- A inhaled short acting beta 2 agonist immediately before exercise
90
What is acute asthma?
It is the progressive worsening of asthma symptoms, including breathlessness, wheeze, cough, and chest tightness.
An acute exacerbation is marked by a reduction in baseline objective measures of pulmonary function, such as peak expiratory flow rate and FEV1
91
Do most asthma attacks that require hospitalisation develop quickly or slowly?
Most asthma attacks severe enough to require hospitalisation develop relatively slowly over a period of six hours or more.
92
In children, what can intermittent wheezing attacks be usually triggered by?
Viral infections and response to asthma medication may be inconsistent
93
What may be risk factors for recurrent wheeze?
Low birth weight
| and/ or prematurity
94
In order to appropriately treat acute exacerbation of asthma what should be correctly differentiated?
Severity should be categorised from poor asthma control
95
What is described as moderate acute asthma?
- Increasing symptoms
- Peak flow >50-75% best or predicted
- No features of acute severe asthma
96
What is described as severe acute asthma?
- Peak flow 33-50% best or predicted
- Respiratory rate > or equal to 25/min
- Heart rate ≥ 110/min
- Inability to complete sentences in one breath
97
What is described as life-threatening acute asthma?
Any one of the following in a patient with severe asthma:
Peak flow
98
What is described as near-fatal acute asthma?
Raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures
99
In children, what is described as moderate acute asthma?
Able to talk in sentences;
Arterial oxygen saturation (SpO2) ≥ 92%;
Peak flow ≥ 50% best or predicted;
Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years;
Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years
100
In children, what is described as severe acute asthma?
Can’t complete sentences in one breath or too breathless to talk or feed;
SpO2 140/minute in children aged 1–5 years; heart rate > 125/minute in children aged over 5 years;
Respiratory rate > 40/minute in children aged 1–5 years; respiratory rate > 30/minute in children aged over 5 years
101
In children what is described as life-threatening acute asthma?
Any one of the following in a child with severe asthma:
SpO2
102
What is the difference in he location/ environment/ setting in which different levels of asthma severity is treated?
Moderate = treated at home or in primary care
Severe or life-threatening = ASAP and be referred to hospital immediately
103
Who should supplementary oxygen be given to?
To all hypoxaemic patients with severe acute asthma to maintain an SpO2 level between 94-98%.
Do not delay if pulse oximetry is unavailable
104
What is the first line treatment of acute asthma?
- A high dose short acting beta 2 agonist (such as salbutamol) given as soon as possible.
105
For patient with mild to moderate acute asthma - how is the beta 2 agonist given?
For patients with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer can be used.
106
For patients with acute severe or life-threatening symptoms, how is administration of beta 2 agonist given?
Administration via an oxygen-driven nebuliser is recommended, if available.
If the response to an initial dose of nebulised short-acting beta2 agonist is poor, consider continuous nebulisation with an appropriate nebuliser.
107
Who are intravenous beta 2 agonists reserved for?
For those patients in whom inhaled therapy cannot be used reliably.
108
In all cases of acute asthma, what must patients be prescribed?
An adequate dose of oral prednisolone.
109
Should ICS still be continued during oral corticosteroid treatment?
Yes
110
What are alternatives to patients who are unable to take oral prednisolone?
- Parenteral hydrocortisone
| - intramuscular methylprednisolone
111
To provide greater bronchodilation, in which patients may nebulised ipratropium bromide be combined with a nebulised beta 2 agonist in patients?
in patients with severe or life-threatening acute asthma, or in those with a poor initial response to beta2 agonist
112
Which compound has should to have some evidence in having bronchodilator effects?
Magnesium sulfate
113
In which patients may intravenous magnesium sulfate be considered?
A single intravenous dose of magnesium sulfate may be considered in patients with severe acute asthma (peak flow
114
When is aminophylline considered in the treatment of acute asthma?
In an acute asthma attack, intravenous aminophylline is not likely to produce any additional bronchodilation compared to standard therapy with inhaled bronchodilators and corticosteroids. However, in some patients with near-fatal or life-threatening acute asthma with a poor response to initial therapy, intravenous aminophylline may provide some benefit.
115
Magnesium sulfate by intravenous infusion or aminophylline should only be used after consultation with who?
After consultation with a senior medical staff.
116
Moving on to the management of acute asthma in children aged 2 years and over, who is supplementary high flow oxygen given to?
Supplementary high flow oxygen (via a tight-fitting face mask or nasal cannula) should be given to all children with life-threatening acute asthma or SpO2
117
In children over , what is first line treatment of acute asthma?
an inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible.
118
When should parents/carers of children with acute asthma at home seek urgent medical attention if initial symptoms are not controlled with up to how many puffs of salbutamol via a spacer?
Up to 10 puffs.
if symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention
119
Urgent medical attention should be sought id the child's symptoms return within how many hours?
Within 3 to 4 hours
if symptoms return within this time, a further or larger dose (maximum of 10 puffs of salbutamol via a spacer) should be given whilst awaiting medical attention
120
In all cases of acute asthma, children should be given an oral dose of what?
Oral prednisolone
121
How many days treatment of oral prednisolone is sufficient in children for acute asthma?
Treatment for up to 3 days, but the length of the course should be tailored to the number of days necessary to bring about recovery.
Repeat the dose in children who vomit and consider the intravenous route in those who are unable to retain oral medication.
122
Can ICS be replaced for oral prednisolone while on acute asthma treatment or vice versa?
It is considered good practice that inhaled corticosteroids are continued at their usual maintenance dose whilst receiving additional treatment for the attack, but they should not be used as a replacement for the oral corticosteroid.
123
Similarly to adult, can nebulised ipratropium bromide be combined with a nebulised beta 2 agonist for children with a poor initial response to beta 2 agonist therapy?
Yes to provide a greater bronchodilation
124
Is magnesium sulfate use a licenced use in children for acute asthma?
Consider adding magnesium sulfate [unlicensed use] to each nebulised salbutamol and ipratropium bromide in the first hour in children with a short duration of severe acute asthma symptoms presenting with an oxygen saturation less than 92%.
125
What intravenous options are there for children with acute asthma?
In children who respond poorly to first-line treatments, intravenous magnesium sulfate [unlicensed use] may be considered as first-line intravenous treatment. In a severe asthma attack where the child has not responded to initial inhaled therapy, early addition of a single bolus dose of intravenous salbutamol may be an option.
Continuous intravenous infusion of salbutamol, administered under specialist supervision with continuous ECG and electrolyte monitoring, should be considered in children with unreliable inhalation or severe refractory asthma
126
Can aminophylline be used as an option in children over 2 years?
Intravenous aminophylline may be considered in children with severe or life-threatening acute asthma unresponsive to maximal doses of bronchodilators and corticosteroids.
127
Where should children under 2 years be treated for acute asthma?
In hospital setting
128
What are the treatment options for children under 2 with acute asthma?
For moderate and severe acute asthma attacks, immediate treatment with oxygen via a tight-fitting face mask or nasal prongs should be given to achieve normal SpO2 saturations of 94-98%. Trial an inhaled short-acting beta2 agonist and if response is poor, combine nebulised ipratropium bromide to each nebulised beta2 agonist dose. Consider oral prednisolone daily for up to 3 days, early in the management of severe asthma attacks.
129
What should be done after every case of acute asthma?
follow up in all cases
Episodes of acute asthma may be a failure of preventative therapy, review is required to prevent further episodes. A careful history should be taken to establish the reason for the asthma attack. Inhaler technique should be checked and regular treatment should be reviewed.
Patients should be given a written asthma action plan aimed at preventing relapse, optimising treatment, and preventing delay in seeking assistance in future attacks.
130
Within how many days of hospital discharge, following an acute asthma attack should the GP review the patient?
It is essential that the patient’s GP practice is informed within 24 hours of discharge from the emergency department or hospital following an asthma attack, and the patient be reviewed by their GP within 2 working days.
131
For how long should a respiratory specialist follow up all patients admitted with a severe asthma attack?
For at least one year after the admission
132
What effect do beta 2 agonists produce?
Bronchodilation
133
Which is the most and effective SABA for asthma?
Salbutamol
134
Given an example of a less selective beta 2 agonist?
Ephedrine -
Less selective beta 2 agonist such as ephedrine are less safe for use as bronchodilators than selective drugs, because they are more likely to cause arrhythmias + other side effects
135
What can inhalation of selective SABA (salbutamol) treat?
Can rapidly treat the mild-moderate symptoms of asthma
136
What role do LABAs (e.g. Salmeterol/ formoterol) have in the management of asthma?
- Role in long term management
| - Also can be useful in nocturnal asthma
137
Can salmeterol be used be used for an asthma attack?
No due to its slower onset of action
138
Is Formoterol licensed for short-term symptom relief?
Yes and for the prevention of exercise induced bronchospasm
FA (Fast acting) - LABA
139
Who are oral preparations of oral beta 2 agonist can useful for?
For patients who cannot manage the inhaled route
140
are inhaled or oral beta 2 agonists more effective?
Inhaled beta 2 agonists are more effective than oral beta 2 agonists.
Oral beta 2 agonists have more side effects
141
For which severity of acute asthma can salbutamol/terbutaline be given intravenously?
- For severe/life threatening acute asthma - but regular use is not recommended as evidence of benefit is uncertain and withdrawal of treatment may be difficult.
142
Can selective beta 2 agonists be used in children under 18 months?
YEs and most are effective by the inhaled route.
143
What type of bronchodilator is ipratropium bromide?
Antimuscarinic bronchodilator
It is a SAMA
Short-acting Muscarinic antagonist
144
How long after administration does the maximal effect of ipratropium bromide occur?
30-60 minutes after use.
145
What is the duration of action of ipratropium bromide?
3-6 hours and bronchodilation can be maintained with treatment 3x daily
146
What is the most common side effect of ipratropium bromide?
- dry mouth is the most common side effect and glaucoma may also occur if given by nebuliser
147
What is the bronchodilator category for tiotropium (via respimat device)?
LAMA
148
What is tiotropium licensed as an adjunct for?
) is licensed as an adjunct to ICS + LABA for maintenance treatment of asthma patients who have suffered 1 or more exacerbations in the last year. It is a LAMA and s.e. is dry mouth.
149
What should be considered about prescribing modified release theophylline?
Modified release theophylline should be prescribed by brand only
150
With theophylline what conditions may increase the plasma concentration of theophylline?
- Heart Failure
- Hepatic impairment
- Elderly
- Drugs which inhibit metabolism (CCBs, Ciprofloxacin and erythromycin)
151
With theophylline what conditions/ lifestyle may decrease the plasma concentration of theophylline?
- smoking
- alcohol
- drugs which induce metabolism (phenobarbital and phenytoin)
152
If theophylline is given with small doses beta 2 agonists what may there be an increased risk of?
Side effects
| - e.g. hypokalaemia
153
How long does bronchodilation from salbutamol last?
3 to 5 hours
154
Patients on salbutamol are at risk of developing hypokalemia when given with which drugs?
- theophylline
| - prednisolone
155
What are the side effects of salbutamol?
- fine tremor
- nervous tension
- headache
- cramps
- palpitations
156
Is ICS a when required medicine?
No it must be used regularly for maximum benefit - (Preventer)
157
When is the full effect of ICS seen?
after 3-7 days
158
What important information needs to be given regarding prescribing beclomethasone?
It must be prescribed by brand - not interchangeable.
e.g. Qvar more potent than Clenil
159
How can the risk of oral candidiasis (thrush) be reduced for those using ICS?
By using a spacer and rinsing the mouth with water
160
What is there a risk of with ICS to do with breathing?
• The risk of Paradoxical bronchospasm means breathing can get worse, resulting in discontinuation of ICS
161
What is Chronic obstructive pulmonary disease (COPD)?
It is a common, largely preventable and treatable disease. characterised by persistent respiratory symptoms and airflow limitation that is usually progressive and not fully reversible.
162
In COPD what is airflow limitation due to a combination of?
- small airways disease (obstructive bronchiolitis)
| - Parenchymal destruction (emphysema)
163
What are the symptoms of COPD?
- Dyspnoea (difficulty in breathing)
- Wheeze
- chronic Cough
- Regular sputum production
164
What is the main factor of development and exacerbations of COPD?
- Tobacco smoking
165
What are other risk factors of COPD exacerbations?
- Environmental pollution
- Occupational exposures
- Genetic factors (such as hereditary alpha alpha-1-antitrpsin deficiency),
- poor lung growth during childhood.
166
What are some complications of COPD?
- Cor Pulmonale
- Depression
- Anxiety
- Type 2 respiratory failure
- Secondary polycythaemia
167
What is Asthma-COPD overlap syndrome (ACOS) ?
It is characterised by persistent airflow limitation that displays features of both asthma and COPD.
168
What are the non drug treatments of COPD?
- Smoking cessation
- pulmonary rehabilitation should be offered to appropriate patients, including those who view themselves as being functionally disabled by COPD
169
What should patients with excessive sputum production be taught?
- active cycle of breathing techniques
| - and how to use positive expiratory pressure devices by a physiotherapist
170
Does weight in COPD need to be monitored?
Yes, Refer patients with a BMI that is abnormal or changing over time for dietetic input, and be attentive to changes in weight in the elderly.
171
Is surgery a possible option for COPD?
Yes, Interventional procedures including surgery may be deemed appropriate following a respiratory review and input from the multidisciplinary team.
172
In terms of vaccinations, what should all patients with COPD be offered?
All patients should be offered the pneumococcal vaccine and annual influenza vaccine
173
What is the initial treatment of COPD in all patients?
Offer a short acting bronchodilator as required to relieve breathlessness and exercise limitation.
This can either be a short-acting beta2 agonist (SABA) or a short-acting muscarinic antagonist (SAMA).
174
Before considering step-up treatment options, what should you ensure to confirm?
_ ensure that COPD is confirmed spirometrically
- ensure relevant vaccinations are given
- non-drug treatment options have been optimised including smoking cessation.
- And short acting bronchodilator is being used
175
What is the step up treatment for patients without asthmatic features or features suggesting steroid responsiveness?
In patients who continue to be breathless or have exacerbations, offer a long-acting beta2 agonist (LABA) and a long-acting muscarinic antagonist (LAMA). Discontinue SAMA treatment if a LAMA is given. Treatment with a SABA as required may be continued in all stages of COPD.
In patients on a LAMA and LABA who have a severe exacerbation (requiring hospitalisation) or at least two moderate exacerbations (requiring systemic corticosteroids and/or antibacterial treatment) within a year, consider the addition of an inhaled corticosteroid (ICS)—triple therapy. If an ICS is given, review at least annually and document the reason for continuation.
In patients on a LAMA and LABA whose day-to-day symptoms continue to adversely impact their quality of life, consider trialling the addition of an ICS for 3 months. If symptoms have improved, continue triple therapy and review at least annually. If there has been no improvement, step back down to a LAMA and LABA combination
176
What is the step up treatment for patients with asthmatic features or features suggesting steroid responsiveness?
In patients who continue to be breathless or have exacerbations, consider treatment with a long-acting beta2 agonist (LABA) and an inhaled corticosteroid (ICS). If an ICS is given, review annually documenting the reason for continuation.
In patients on a LABA and ICS who have a severe exacerbation (requiring hospitalisation) or at least two moderate exacerbations (requiring systemic corticosteroids and/or antibacterial treatment) within a year, or who continue to have day-to-day symptoms adversely impacting their quality of life, add a long-acting muscarinic antagonist (LAMA)—triple therapy. Discontinue SAMA treatment if a LAMA is given. Treatment with a SABA as required may be continued in all stages of COPD.
177
Is prophylactic antibiotics an option for treatment of COPD?
- Yes but unlicensed use
(Azithromycin)
After considering if respiratory specialist input is required, consider azithromycin [unlicensed] prophylaxis to reduce the risk of exacerbations in patients who are non-smokers, have had all other treatment options optimised, and who continue to either have prolonged or frequent (4 or more per year) exacerbations with sputum production, or exacerbations resulting in hospitalisation.
178
To use prophylaxis antibiotics what monitoring/ tests should be carried out?
Ensure sputum culture and sensitivity testing, a CT scan of the thorax (to rule out other lung pathologies), a baseline ECG (to rule out QT prolongation), and LFTs are performed before offering prophylaxis. Review treatment after the first 3 months, then at least 6 monthly thereafter; only continue if benefits outweigh risks.
179
What are other treatment options in COPD?
- Roflumilast s recommended as add-on treatment to bronchodilator therapy in patients with severe COPD with chronic bronchitis (respiratory specialist initiation only)
- consider mucolytic treatment in patients with chronic cough productive of sputum; only continue if symptomatic improvement is seen (Antitussive drugs - cough suppressant should not be used in the management of stable COPD)
180
Can theophylline be used in the management of COPD?
Modified-release theophylline should only be used after a trial of short-acting and long-acting bronchodilators, or if the patient is unable to use inhaled treatment
181
What should be created for those at risk of exacerbation of COPD?
- Together with the patient, action plans should be created
182
In patients who have had an exacerbation of COPD which meds should be kept at home? (HINT - rescue pack)
In patients who have had an exacerbation within the last year, a short course of antibacterials (non-macrolide if on prophylactic azithromycin) and oral corticosteroids should be kept at home.
183
For those on prophylactic azithromycin can they continue to take these during an acute exacerbation?
Yes
184
Which non drug treatment can help with sputum clearance?
- consider physiotherapy using positive expiratory pressure devices
185
What is the drug treatment steps for treatment of COPD exacerbations?
- give short acting bronchodilators, usually at higher doses than the patient's maintenance dose
(With hold LAMA treatment of SAMA is given)
In the absence of significant contraindications in patients that present to hospital with an exacerbation, use a short course of prednisolone along with other therapies. Consider a short course for patients in the community experiencing an exacerbation with a significant increase in breathlessness that interferes with daily activities. Consider osteoporosis prophylaxis for patients who require frequent courses of oral corticosteroids
186
For COPD exacerbation management is long term corticosteroid treatment recommended?
No - however in some patients this may need to be continued when withdrawal following an exacerbation is not possible; the lowest dose possible should be used.
Start prophylaxis for osteoporosis without monitoring in patients above 65 years old.
187
Is aminophylline used in COPD exacerbation management?
Aminophylline should only be used as add-on treatment when there is an inadequate response to nebulised bronchodilators; ensure therapeutic drug monitoring is performed and that previous oral theophylline use is considered to avoid toxicity.
188
Is oxygen used in the management of COPD exacerbation?
If necessary, oxygen should be given to ensure oxygen saturation of arterial blood levels are kept within the target range for the patient
189
Is there an increased sputum production in COPD?
Yes causing a productive cough.
The mucous production also causes an obstruction in the bronchioles making it difficult to breathe out.
190
What is the difference between FEV1 and FVC?
FEV1, or forced expiratory volume in one second, is the volume of breath exhaled with effort in that timeframe.
FVC, forced vital capacity, is the full amount of air that can be exhaled with effort in a complete breath
191
What are the two types of COPD?
- Bronchitis
| - Emphysema (the alveoli (air spaces) become enlarged)
192
In COPD why is there an increase in the partial pressure of CO2?
The mucous plugs in the bronchioles block air flow making it difficult to breathe out (we breathe out CO2). This increases the partial pressure of CO2 and a decreases the partial pressure of O2.
193
To summarise treatment of COPD, what is the first line?
For breathlessness and exercise limitation:
- SABA (Salbutamol) as required (may continue at all stages
OR
- SAMA (Ipratropium) as required
194
If FEV1 is greater than or equal to 50% then what is the next treatment steps of COPD?
- LABA (salmeterol)
| - LAMA (discontinue SAMA)
195
If FEV1 is greater than or equal to 50% but LABA and LAMA are not enough then what should 3rd line?
LABA + ICS (combination)
+
LAMA
(Triple therapy)
196
If FEV1 is less than 50% then what is the next treatment steps of COPD after 1st line treatment failed?
LABA + ICS (combination inhaler)
IF ICS is CI then try LAMA (Discontinue SAMA)
197
If FEV1 is less than 50% then what is the next treatment steps of COPD (third line)?
Triple therapy
LABA + ICS (Combination inhaler)
+
LAMA
198
Which mucolytic drug can be used in COPD?
mucolytic drug (Carbocisteine) can be used for a patient with a chronic productive cough. It reduces mucous production + viscosity. Discontinue after 4 weeks if NO IMPROVEMENT.
199
When is oxygen therapy indicated?
If partial pressure of oxygen is less than 7.3kPa
(long term) for more than 15 hours reduces mortality. It is given when the partial pressure of oxygen is <7.3kPa. it increases the partial pressure to >8kPa.
200
Who is oxygen given to?
It is prescribed for hypoxemic patients to increase alveolar oxygen tension and decrease the work of breathing.
201
In most patients what oxygen saturation with oxygen treatment should you aim for?
94 - 98% oxygen saturation
202
Which patients, is a lower target of 88-92% indicated in?
A lower target of 88–92% oxygen saturation is indicated for patients at risk of hypercapnic respiratory failure.
203
In which conditions is high concentrations of oxygen therapy safe in and why?
High concentration oxygen therapy is safe in uncomplicated cases of conditions such as pneumonia, pulmonary thromboembolism, pulmonary fibrosis, shock, severe trauma, sepsis, or anaphylaxis. In such conditions low arterial oxygen (PaO2) is usually associated with low or normal arterial carbon dioxide (PaCO2), and therefore there is little risk of hypoventilation and carbon dioxide retention.
204
Is it safe to use high concentrations of oxygen therapy in acute severe asthma?
Yes - the arterial carbon dioxide (PaCO2) is usually subnormal but as asthma deteriorates it may rise steeply (particularly in children). These patients usually require high concentrations of oxygen and if the arterial carbon dioxide (PaCO2) remains high despite other treatment, intermittent positive-pressure ventilation needs to be considered urgently.
205
Low concentration oxygen therapy (controlled oxygen therapy) is reserved for patients at risk of hypercapnic respiratory failure. In which group of patients/ medical conditions is there an increased risk of this?
chronic obstructive pulmonary disease (COPD);
advanced cystic fibrosis;
severe non-cystic fibrosis bronchiectasis;
severe kyphoscoliosis or severe ankylosing spondylitis;
severe lung scarring caused by tuberculosis;
musculoskeletal disorders with respiratory weakness, especially if on home ventilation;
an overdose of opioids, benzodiazepines, or other drugs causing respiratory depression
206
Until blood gases can be monitored, oxygen should be given using a controlled concentration of?
24 or 28% titrated towards a target oxygen saturation of 88-92% or the level specified on the patient's oxygen alert card if available.
207
What is the aim of controlled oxygen therapy and not giving to high concentrations?
he aim is to provide the patient with enough oxygen to achieve an acceptable arterial oxygen tension without worsening carbon dioxide retention and respiratory acidosis.
208
What should patients and carers be given who have had an episode of hypercapnic respiratory failure?
should be given a 24% or 28% Venturi mask and an oxygen alert card endorsed with the oxygen saturations required during previous exacerbations. Patients and their carers should be instructed to show the card to emergency healthcare providers in the event of an exacerbation.
209
What should be considered before home oxygen prescription?
Patients should be advised of the risks of continuing to smoke when receiving oxygen therapy, including the risk of fire. Smoking cessation therapy should be recommended before home oxygen prescription.
210
Can home oxygen prescription be given for COPD?
In patients with COPD, it should only be provided if the patient has stopped smoking.
211
How long is long term oxygen therapy?
usually at least 15 hours which improves survival in COPD patients with more severe hypoxaemia.
212
IN patients with COPd, what level of FEV1 should you consider oxygen?
FEV1 less than 30% predicted (consider assessment if FEV1 is 30-49%)
When oxygen saturations levels are less than 92% or less breathing air.
213
For assessment for long term oxygen - how is it done?
Assessment for long-term oxygen therapy requires measurement of arterial blood gas tensions. Measurements should be taken on 2 occasions at least 3 weeks apart to demonstrate clinical stability.
214
In which patients should long term oxygen therapy be considered for?
COPD with PaO2 <7.3 kPa when stable and who do not smoke (minimum of 15 hours per day);
COPD with PaO2 7.3–8 kPa when stable and do not smoke, and also have either secondary polycythaemia, peripheral oedema, or evidence of pulmonary hypertension (minimum of 15 hours per day);
severe chronic asthma with PaO2<7.3 kPa or persistent disabling breathlessness;
interstitial lung disease with PaO2<8 kPa and in patients with PaO2>8 kPa with disabling dyspnoea;
cystic fibrosis when PaO2<7.3 kPa or if PaO2 7.3–8 kPa in the presence of secondary polycythaemia, nocturnal hypoxaemia, pulmonary hypertension, or peripheral oedema;
pulmonary hypertension, without parenchymal lung involvement when PaO2<8 kPa;
neuromuscular or skeletal disorders, after specialist assessment;
obstructive sleep apnoea despite continuous positive airways pressure therapy, after specialist assessment;
pulmonary malignancy or other terminal disease with disabling dyspnoea;
heart failure with daytime PaO2<7.3 kPa when breathing air or with nocturnal hypoxaemia;
paediatric respiratory disease, after specialist assessment.
215
Which signs or symptoms prompt patients and their relatives to call for medical help suggestive of respiratory depression when being treated with low concentrations of oxygen?
drowsiness or confusion occur
216
If long term oxygen is given, how often should this be revieweed?
At least annually
Do not offer long-term oxygen therapy to patients who continue to smoke despite being offered smoking cessation interventions
217
What can short burst oxygen therapy be used for?
to improve exercise capacity and recovery; it should only be continued if there is proven improvement in breathlessness or exercise tolerance.
218
Is short burst oxygen therapy recommended in COPD?
It is not recommended for COPD patients who have mild or no hypoxaemia at rest.
219
Which patients is ambulatory oxygen prescribed for?
Ambulatory oxygen is prescribed for patients on long-term oxygen therapy who need to be away from home on a regular basis.
Patients who are not on long-term oxygen therapy can be considered for ambulatory oxygen therapy if there is evidence of exercise-induced oxygen desaturation and of improvement in blood oxygen saturation and exercise capacity with oxygen.
220
Can ambulatory oxygen therapy be used in COPD patients?
No
not recommended for patients with heart failure, COPD with mild or no hypoxaemia at rest, or those who smoke.
221
Under the NHS oxygen may be supplied as what?
Oxygen cylinders
222
Oxygen flow can be adjusted, what are the flow rates of medium and high setting?
oxygen flow meter with ‘medium’ (2 litres/minute) and ‘high’ (4 litres/minute) settings.
223
A oxygen concentrator is more economical for patients who require oxygen for a long period - which patients is a concentrator recommended for?
patient who requires oxygen for more than 8 hours a day (or 21 cylinders per month)
224
What are the advantages/ disadvantages of giving oxygen via a nasal cannula?
allows the patient to talk, eat, and drink, but the concentration of oxygen is not controlled; this may not be appropriate for acute respiratory failure.
225
Which oxygen services may be ordered in England and Wales?
emergency oxygen;
short-burst (intermittent) oxygen therapy;
long-term oxygen therapy;
ambulatory oxygen
226
What does the clinician need to obtain before ordering oxygen therapy?
The clinician should obtain the patient or carers consent, to pass on the patient’s details to the supplier, the fire brigade, and other relevant organisations.
227
What is croup?
It is a common childhood condition that mainly affects babies and young children's airways.
It is usually mild.
228
Is croup self-limiting?
Yes but treatment with a single dose of a corticosteroid (e.g.) dexamethasone by mouth may be of benefit
229
How many doses of corticosteroids (e.g. dexamethasone or prednisolone by mouth) should be administered while awaiting hospital admission?
- A single dose of a corticosteroid
230
If the child is too unwell to receive oral medication then what should be given instead?
dexamethasone (by intramuscular injection) or budesonide (by nebulisation) are suitable alternatives while awaiting hospital admission.
231
For severe croup not effectively controlled with corticosteroid treatment, what can be given?
nebulised adrenaline/epinephrine solution 1 in 1000 (1 mg/mL) should be given with close clinical monitoring; the clinical effects of nebulised adrenaline/epinephrine last at least 1 hour, but usually subside 2 hours after administration. The child needs to be monitored carefully for recurrence of severe respiratory distress.
232
Give examples of inhaled antimuscarinics?
- Aclidinium bromide
- Glycopyrronium bromide
- ipratropium bromide
- Tiotropium
- Umeclidinium
- Umeclidinium with vilanterol
233
Which inhaled antimuscarinics are short acting (SAMA)?
Ipratropium
234
Which inhaled antimuscarinics are long acting (LAMA)?
- Tiotropium
- Glycopyrronium
- umeclidinium
- Aclidinium
235
What are the common side effects of anti-muscarinic inhaled drugs?
- Arrythmias
- Constipation
- cough
- dizziness
- dry mouth
- headache
- nausea
236
What is the active ingredient in Eklira inhaler?
Aclidinium bromide
| LAMA
237
What is the active ingredient in Duaklir?
Aclidinium bromide + Formoterol
238
What is the brand name of the inhaler for glycopyrronium bromide?
Seebri breezhaler
239
Which ingredients are included in ultibro breezhaler?
Glycopyrronium with indacterol
240
For ipratropium inhaler what should carers and patients know?
Should be counselled on the administration technique and warned against accidental contact with the eye (due to risk of ocular complications)
241
What active ingredient does spiriva respimat have?
Tiotropium (LAMA)
242
Respimat inhaler - how many times can it be used before it needs to be replaced even though it is resusable?
- 6 cartridges
243
Which potential serious electrolyte imbalance can occur from beta 2 agonist therapy?
Hypokalaemia - which can be worsened when taken with corticosteroids, diuretics, theophylline and by hypoxia
244
When beta 2 agonists are given intravenously what is there a risk of for diabetic patients?
- it can cause hyperglycaemia
| - also ketoacidosis
245
Give examples of long acting beta 2 selective agonists (LABA)?
- Bambuterol
- Formoterol
- Olodaterol
- Salmeterol
246
What must be clearly stated on the directions on inhaled beta 2 agonists?
The maximum number of inhalations in 24 hours of the beta 2 agonist should be stated explicitly to the patient or their carer.
247
Give examples of short acting beta agonists (SABA)?
- Salbutamol
| - Terbutaline
248
What are some of the side effects of salbutamol?
- Muscle cramps
- akathisia
- Vasodilation (headaches, flushes)
- metabolic change, myocardial ischaemia
- Pulmonary oedema
- Lactic acidosis with very high doses
249
What MHRA warning was given regarding inhaled corticosteroid ue and risk of central serious chirioretinopathy?
The MHRA recommends that patients should be advised to report any blurred vision or other visual disturbances with corticosteroid treatment given by any route; consider referral to opthamaligist if this is suspected
250
What are the side effects of inhaled corticosteroids?
- Headache
- oral candidiasis
- pneumonia (in patients with COPD)
- taste altered
- Voice alteration
Uncommon - anxiety, bronchospasm paradoxical, cataract, vision blurred.
251
How can the risk of oral candidiasis be reduced with ICS use?
- by using a spacer device with the corticosteroid inhaler
- rinsing mouth with water after inhalation of a dose
- An anti-fungal gel or oral suspension can be used to treat oral candidiasis without discontinuing corticosteroid therapy
252
What can be done for paradoxical bronchospasm caused by ICS?
The potential for paradoxical bronchospasm (calling for discontinuation and alternative therapy) should be bourne in mind
- Mild bronchospasm may be prevented by inhalation of a short-acting beta 2 agonist beforehand (or by transfer from an aerosol inhalation to a dry powder inhalation).
253
Can ICS for asthma be taken as normal during pregnancy and breastfeeding?
Yes
254
Does beclomethasone need to be prescribed by brand and if yes or no then state why?
Yes
Different brands have different potencies
Qvar is twice as potent as clenil as an example.
Qvar has extra-fine particles, is more potent than traditional beclomeasone dipropionate - containing inhalers.
255
Which ingredient is included in Soprobec?
Beclometasone
256
Which ICS (beclometasone) are unlicensed in children?
Easyhaler beclometasone is not licensed to be used in children
Clenil 200 and 250 are mot licensed for use in children
257
Whats the guidance for switching a patient with well controlled asthma from beclometasone generic or other to Qvar as they are not interchangeable?
- Initially a 00 microgram metered dose of Qvar should be prescribed for 200-250 micrograms of beclometasone or budesonide and for 100 micrograms of fluticasone propionate
258
Whats the guidance for switching a patient with poor controlled asthma from beclometasone generic or other to Qvar as they are not interchangeable?
- Initially a 00 microgram metered dose of Qvar should be prescribed for 100 micrograms of beclometasone or budesonide or fluticasone propionate
259
Which inhaler is listed in the dental practitioners formulary?
- Clenil Modulite 50 micrograms/ metered inhalation
260
What is the MHRA guidance on fostair?
The beclometasone contained in that inhaler is more potent (finer particles) compared to some other fostairs
- 100 micrograms of beclometasone extrafine in fostair is equivalent to 250 micrograms of beclometasone in non-extrafine formulation.
261
Which active ingredients are contained in Trimbow inhaler?
- Beclometasone (ICS)
Formoterol (LABA)
- Glycopyrronium (LAMA)
262
How does budesonide work?
It is a glucocorticoid, which exerts significant local anti-inflammatory effects.
263
Does budesonide come in dry powder inhaler or pressured metered inhaler?
- Dry powder (quick and deep)
264
Which ingredients is contained in Symbicort?
- Budesonide (ICS)
| - Formoterol (LABA)
265
What is the brand name of fluticasone (ICS) inhaler?
Flixotide evohaler
266
What is the brand name of the inhaler that contains fluticasone + Formoterol?
Flutiform
267
Which ingredients is contained in seretide inhaler?
Fluticasone (ICS) + Salmeterol (LABA)
268
Which ingredients is included in relvar ellipta?
Fluticasone (ICS) +
| Vilanterol (LABA)
269
For the prophylaxis of asthma what is the doses of Montelukast depending on the ages?
Child 6 months - 5 years - 4mg once daily, dose to be taken in the evening
Child 6-14 years - 5mg once daily, dose to be taken in the evening
Child 15 - 17 years and Adult - 10mg once daily, dose to be taken in the evening
270
What drug class does roflumilast fall in?
Phosphodiesterase type 4 inhibitors
271
Which group does ephedrine fall in?
It is a sympathomimetics - vasoconstrictor
272
Which group of meds/ category do aminophylline and theophylline fall in?
Xanthines
273
Which age is aminophylline injection not licensed in?
Not licensed for under 6 months
274
Can aminophylline be used if patient has been previously treated with theophylline?
Yes but should not receive a loading dose
275
For aminophylline what is the therapeutic range?
10-20mg/L
276
When given intravenously when should the measurement be taken after a dose?
4-6 hours after starting treatment and at least 3 days after a dose change
277
What is the direction administration for aminophylline (IV)?
For IV manufacturer advises give very slowly over at least 20 minutes with close monitoring
278
Which antihistamines may have a role in nausea and vomiting?
- Cinnarizine
- Cyclizine
- Promethazine
279
Which other condition may some antihistamines have a role in?
occasional Insomnia
280
Do all older antihistamines cause sedation?
Yes all older antihistamines cause sedation but alimemazine and promethazine may be more sedating whereas chlorphenamine and cyclizine may be less.
281
List examples of non-sedating antihistamines?
acrivastine, bilastine, cetirizine hydrochloride, desloratadine (an active metabolite of loratadine), fexofenadine hydrochloride (an active metabolite of terfenadine), levocetirizine hydrochloride (an isomer of cetirizine hydrochloride), loratadine and mizolastine cause less sedation and psychomotor impairment than the older antihistamines because they penetrate the blood brain barrier only to a slight extent.
282
What considerations should be taken in to account regarding antihistamines in the elderly?
- The use of first-generation antihistamines in elderly patients is potentially inappropriate (STOPP criteria) as safer, less toxic antihistamines are widely available
283
What is a use of Omalizumab (a monoclonal antibody)?
It is a monoclonal antibody that binds to immunoglobulin E (IgE).
It is used as additional therapy in individuals with proven IgE-mediated sensitivity to inhaled allergens, whose severe persistent allergic asthma cannot be controlled adequately with high dose inhaled corticosteroid together with a long-acting beta2 agonist. Omalizumab should be initiated by physicians in specialist centres experienced in the treatment of severe persistent asthma.
Omalizumab is also indicated as add-on therapy for the treatment of chronic spontaneous urticaria in patients who have had an inadequate response to H1 antihistamine treatment.
284
What is anaphylaxis?
It is a severe, life-threatening, generalised or systemic hypersensitivity reaction.
285
What is the most common allergens that cause anaphylaxis?
- Food (e.g. peanuts, sesame, tree nuts, soy shellfish and cow's milk)
- Some drugs (e.g. antibacterials, aspirin and other NSAIDS, neuromuscular blocking drugs, Chlorhexedine, contrast media and vaccines)
- Venom (e.g. insect bites)
- and latex
286
In the case of drugs is anaphylaxis more likely with oral or parenteral administration?
More likely after parenteral administration
287
What may anaphylactic drugs also be associated with?
- additives
| - excipients in foods and medicines
288
Is refined Arachis (peanut) oil likely to cause an anaphylactic reaction?
This may be present in some medicinal products but it is unlikely to cause an allergic reaction - nevertheless it is wise to check the full formula of preparations which may contain allergens.
289
What is the initial management or step of anaphylaxis?
- Immediately call for an ambulance or the resuscitation team and begin initial treatment for anaphylaxis.
290
What are the remainder steps of management of anaphylaxis?
- Remove the trigger causing the anaphylactic reaction if possible (e.g. stopping the suspected drug or removing the stinger after an insect sting)
- place the patient in a comfortbale position taking into account their presenting signs and symptoms - lay the patient flat (with or without legs raised) to ain in restoration of blood pressure
- Or in a semi-recumbent position for patients with airway and breathing problems (and no evidence of cardiovascular instability) to make breathing easier
- Or in the recover position for unconscious patients who are breathing normally
291
Which side left or ride should pregnant women lie in?
On their left side to prevent aortocaval compression
292
What is the first line drug treatment for anaphylaxis?
- Intramuscular adrenaline/epinephrine
| - If there is doubt about the diagnosis, give intramuscular adrenaline/ epinephrine and seek medical advice
293
What does adrenaline/epinephrine provide?
It provides psychological reversal of the immediate symptoms associated with hypersensitivity reactions
294
How should you assess treatment for anaphylaxis after giving adrenaline/ epinephrine?
- Monitor vital signs (such as blood pressure, pule, respiratory function and level of consciousness). and auscultate for wheeze.
295
If there is not improvement after giving intramuscular adrenaline/epinephrine then wehn must dose be repeated?
After a 5 minute interval
Patients who have no improvement in respiratory and/or cardiovascular problems despite 2 appropriate doses of intramuscular adrenaline/epinephrine, should have their care escalated quickly and managed as having refractory anaphylaxis.
296
Can nebulised adrenaline/epinephrine be effective as an adjunct to treat upper airways obstruction cause by laryngeal oedema?
Yes but only after treatment with intramuscular adrenaline/epinephrine and not as an alternative
297
For anaphylaxis, high-flow oxygen should be given as soon as it is available - True or false?
True
298
Who should intravenous fluid be given to?
Intravenous fluids should be given to patients with hypotension/shock, or if there is poor response to an initial dose of adrenaline/epinephrine
299
Are antihistamines recommended for the initial emergency treatment of anaphylaxis?
Antihistamines are not recommended as part of the initial emergency treatment of anaphylaxis.
300
After stabilisation, which antihistmaine may be recommended?
a non-sedating oral antihistamine such as cetirizine hydrochloride (in preference to chlorphenamine maleate) may be considered, especially in patients with persistent cutaneous symptoms (urticaria and/or angioedema). If oral administration is not possible, intramuscular or intravenous chlorphenamine maleate can be given.
301
Is the routine use of corticosteroids for the emergency treatment of anaphylaxis recommended?
No it is not recommended
Consider corticosteroids after initial resuscitation for refractory reactions or ongoing asthma/shock; corticosteroids must not be given preferentially to adrenaline/epinephrine. Corticosteroids should be given via the oral route where possible.
302
Can inhaled bronchodilator therapy with salbutamol and/or ipratropium bromide be considered in anaphylaxis?
Yes, may also be considered for patients with persisting respiratory problems, but should not be used as an alternative to further treatment with adrenaline/epinephrine
303
What is refractory anaphylaxis defined as?
Refractory anaphylaxis is defined as anaphylaxis that requires ongoing treatment due to persisting respiratory and/or cardiovascular problems despite 2 appropriate doses of intramuscular adrenaline/epinephrine—seek early critical care support.
304
What is the treatment for refractory anaphylaxis?
- intravenous adrenaline/epinephrine
- Intravenous adrenaline/epinephrine should only be given by experienced specialists and in a setting where patients can be carefully monitored. If an intravenous infusion cannot be administered safely (e.g. due to a patient being outside a hospital setting), continue to give intramuscular adrenaline/epinephrine at 5-minute intervals while life-threatening cardiovascular and/or respiratory features persist.
305
what should adrenaline/epinephrine therapy be supported with?
Adrenaline/epinephrine therapy should be supported with intravenous fluid therapy.
306
Prior to discharge from hospital after anaphylactic shock, how many adrenaline/epinephrine auto-injectors should patients or their family or carers be provided with?
2 auto-injectors
307
Who is it appropriate to give supply of the auto-injectors?
The provision of adrenaline/epinephrine auto-injectors are appropriate for all patients who have had anaphylaxis, with the exception of those with a drug-induced reaction (unless future exposure to the trigger drug will be difficult to avoid).
308
During discharge what other information should patients and their family or carers be provided with?
Patients and their family or carers should also be provided with information about anaphylaxis, the risk of a biphasic reaction (with clear instructions to return to hospital if symptoms return), avoidance of suspected triggers, and what to do if an anaphylactic reaction occurs. An emergency management or action plan should be provided, and referral to a specialist allergy clinic made.
309
What is allergic angiodema?
Angioedema can be caused by an allergic reaction.
It involves the swelling of deeper tissues, most commonly in the eyelids and lips, and sometimes the tongue and throat.
Allergic angioedema that occurs with life-threatening airway and/or breathing and/or circulatory problems should be managed as anaphylaxis
310
What's the treatment for Hereditary angioedema?
The treatment of hereditary angioedema should be under specialist supervision. Unlike allergic angioedema, adrenaline/epinephrine, corticosteroids, and antihistamines should not be used for the treatment of acute attacks (including attacks involving laryngeal oedema) as they are ineffective and may delay appropriate treatment—intubation may be necessary.
311
Which drugs are used for hereditary angioedema?
The administration of C1-esterase inhibitor, an endogenous complement blocker derived from human plasma, (in fresh frozen plasma or in partially purified form) can terminate acute attacks of hereditary angioedema; it can also be used for short-term prophylaxis before dental, medical, or surgical procedures. Conestat alfa and icatibant are licensed for the treatment of acute attacks of hereditary angioedema in adults with C1-esterase inhibitor deficiency.
312
What are the doses of intramuscular injection of adrenaline (epinephrine) for emergency treatment of anaphylaxis by HCPs?
Child up to 6 months - 100-150 micrograms
Child 6 months to - 5 years - 150 micrograms
Child 6 to 1 years - 300 micrograms
Child 12 and over and adults = 500 micrograms
313
Is Desloratidine a sedating or non sedating antihistamine?
Non-sedating
314
List all the non-sedating antihistamines?
- Acrivastine (Bendaryl allergy relief)
- Bilastine
- Cetirizine
- Desloratidine
- Fexofenadine
- Levocetirizine
- Loratidine
- Misolastine
- Rupatadine
315
For cetirizine what eGFR should it be avoided in?
Avoid if less than 10
316
List the sedating antihistamines?
Alimenazine
- Chlorphenamine
- Clemastine
- Cyproheptadine
- Hydroxyzine hydrochloride
- Ketotifen
- Promethazine hydrochloride
317
How does hydroxizine hydrochloride work?
Hydroxyzine is a sedating antihistamine which exerts its actions by antagonising the effects of histamine
318
What is the MHRA warning regarding hydroxyzine?
small risk of QT interval prolongation
- So it is now CI in patients with prolonged QT interval or who have risk factors for QT interval prolongation
- avoid use in elderly due to increased susceptibility to the side effects of hydroxyzine.
- consider extra to patients on meds to lower heart rate and hat lower potassium levels.
319
What are some allergen-type vaccines that can be used in vaccines to reduce hypersensitivity reactions?
- Bee venom extract
- Grass pollen extract
- Tree pollen extract
- Wasp venom extract
320
Which drugs are used to treat hereditary angioedema?
C1-esterase inhibitor
Conestat alfa
Lanadelumab
Icatibant
321
Name 3 mucolytics that are used to reduce sputum viscosity?
Acetylcysteine
Carbocisteine
Erdosteine
322
What is the main clinical signs of cystic fibrosis?
- Pulmonary disease
- with recurrent infections
- production of copious viscous sputum
- Malabsorption due to pancreatic insufficiency
323
What are some complications of cystic fibrosis?
hepatobiliary disease, osteoporosis, cystic fibrosis-related diabetes, and distal intestinal obstruction syndrome
324
What is the aims of treatment of cystic fibrosis?
- preventing and managing lung infections
- loosening and removing thick, sticky mucus from the lungs
- preventing or treating intestinal obstruction
- providing sufficient nutrition and hydration
325
what is lung function a key predictor of in people with cystic fibrosis?
- Life expectancy
326
What are the non-drug treatment options for cystic fibrosis?
- specialist physiotherapists should assess patients with cystic fibrosis
- provide advice on airway clearance, nebuliser use, muscoskeletal disorders, physical activity, and urinary incontinence.
Patients should be advised that regular exercise improves both lung function and overall fitness.
327
What is treatment of cystic fibrosis based on?
To prevent lung infection and the maintenance of lung function
328
How often should patients be reviewed with cystic fibrosis?
- at least every 3 months
| - but frequency should be based on their clinical condition
329
What drug to reduce sputum viscosity should patients with cystic fibrosis be offered?
A mucolytic
330
What is the first line mucolytic used in cystic fibrosis?
- Dornase alfa and hypertonic sodium chloride
or hypertonic sodium chloride alone should be considered
331
What is available alternative is dornase alfa is unsuitable?
Mannitol dry powder for inhalation is recommended as an option when dornase alfa is unsuitable (because of ineligibility, intolerance, or inadequate response), when lung function is rapidly declining, and if other osmotic drugs are not considered appropriate
332
Can lumacaftor with ivacaftor be used to treat cystic fibrosis?
No it is not recommended for treating cystic fibrosis within its marketing authorisation
333
Can long term antibacterial be considered to supress chronic staph. aureus respiratory tract infections in patients whose pulmonary disease is stable?
YEs
334
Can antibacterials be routinely used to supress chronic MRSA in patients?
No - Antibacterials should not be routinely used to suppress chronic MRSA in patients with stable pulmonary disease
335
Regarding bones - what should patients be monitored for
- Cystic fibrosis-related bone mineral density
336
Regarding bones - what should patients be monitored for and diabetes?
- Cystic fibrosis-related bone mineral density
| - should be monitored for cystic-fibrosis related diabetes
337
Is codeine phosphate useful for cough as a cough supressant?
- Some evidence suggests that codeine provides no benefit for symptoms of acute cough
- Codeine is also constipating and can cause dependence
338
Instead of codeine what cough supressants are recommended?
- Pholcodine and dextromethorphan have fewer side effects
339
Which type of antihistamine may be used as a cough supressant?
- Sedating antihistamines - all tend to cause drowsiness which may reflect their main mode of action
340
what are demulcent cough preparations?
Contain soothing substances such as syrup or glycerol and some patients believe that such preparations relieve a dry irritating cough
341
Give an example of demulcent cough preparation?
Simple linctus - which has advantage of being harmless and inexpensive
- paediatric simple linctus is particularly useful in children
Also soothing substances such as syrup or glycerol
342
What do expectorants do?
They claim to promote expulsion of bronchial secretions, but there is no evidence that any drug can specifically facilitate expectoration
343
Give an over the counter example of a expectorant?
- Guaifenesin - which may be used for acute cough - there is some evidence to suggest it may reduce symptoms.
344
So are nasal decongestants for administration for mouth more effective than local application?
No
345
What is an advantage about nasal decongestants by mouth?
- They do not give rise to rebound nasal congestion on withdrawal
346
The use of strong aromatic decongestants (applied as rubs or to pillows) is not advised for infants under the age of what?
Under the age of 3 months
- Sodium chloride 0.9% given as nasal drops is preferred
- administration before feeds may ease feeding difficulties caused by nasal congestion
347
The over the counter cough supressants containing codeine phosphate should be avoided in children under what age?
12 years old
348
And also children of any age who are ultra rapid metabolisers for which enzyme?
CYP2D6 - as ultra rapid metabolisers mean higher concentration of the metabolite.
349
Cough suppressants containing similar opioid analgesics such as dextromethorphan and pholcodine are not generally recommended in children and should be avoided in children under what age?
under 6 Years
350
Dextromethorphan should be avoided in children under what age?
Under the age of 12
351
The MHRA warning states children under 6 years should not be given over-the-counter cough and cold medicines containing which ingredients?
brompheniramine, chlorphenamine maleate, diphenhydramine, doxylamine, promethazine, or triprolidine (antihistamines);
dextromethorphan or pholcodine (cough suppressants);
guaifenesin or ipecacuanha (expectorants);
Phenylephrine hydrochloride, pseudoephedrine hydrochloride, ephedrine hydrochloride, oxymetazoline, or xylometazoline hydrochloride (decongestants)
352
For children aged 6-12 years how many days cough and cold medicines treatment should they be restricted to?
5 days or less
- Children should not be given more than 1 cough or cold preparation at a time because different brands may contain the same active ingredient; care should be taken to give the correct dose
353
What age can pholcodine be used for?
6 years and over
| For dry cough
354
What is citric acid formulated as?
- Simple linctus
355
What is idiopathic pulmonary fibrosis (IPF)?
It is a condition in which the lungs become scarred and breathing becomes increasingly difficult.
It is not clear what causes it
356
Which ages does idiopathic pulmonary fibrosis affect?
usually affects people who are around 70 to 75 years old, and is rare in people under 50
357
Is there a treatment available that can stop or reverse the scarring of the lungs caused by idiopathic pulmonary fibrosis?
No although there are several treatments that can help reduce the rate at which IPF gets worse.
358
Which drug can be used to slow the progression of idiopathic pulmonary fibrosis?
Pirfenidone
It has antifibrotic and anti-inflammatory properties
359
What MHRA warning has been issued regarding the use of pirfenidone?
- Reports of drug induced liver injury (including liver failure)
360
What is the scientific name for respiratory stimulants?
- Analeptic drugs
361
When are respiratory stimulants (analeptic drugs)?
They are effective only when given by intravenous injection or infusion and have a short duration of action.
362
When are respiratory stimulants used?
Their use has largely been replaced by ventilatory support including nasal intermittent positive pressure ventilation. However, occasionally when ventilatory support is contra-indicated and in patients with hypercapnic respiratory failure who are becoming drowsy or comatose, respiratory stimulants in the short term may arouse patients sufficiently to co-operate and clear their secretions.
363
Can respiratory stimulants be used in respiratory failure?
Respiratory stimulants can also be harmful in respiratory failure since they stimulate non-respiratory as well as respiratory muscles. They should only be given under expert supervision in hospital and must be combined with active physiotherapy. There is at present no oral respiratory stimulant available for long-term use in chronic respiratory failure.
364
List an example of a respiratory stimulant?
- Doxapram hydrochloride
365
In which conditions should oral decongestants be used with caution?
- Diabetes
- Hypertension
- Hyperthyroidism
366
In patients taking which class of medication should decongestants be avoided in?
In patients taking monoamine-oxidase inhibitors
367
Desensitizing vaccines should only be used for what?
- seasonal allergic hayfever (caused by pollen) that has not responded to anti-allergic drugs + hypersensitivity to wasp and bee venoms
368
Desentising vaccine should generally be avoided or used with which patients?
with patients with asthma
