Chapter 3: Respiratory System Flashcards
Update: Theophylline
Monotherapy in COPD is not appropriate - safer, more effective alternatives are available. Must be given alongside other medicines in COPD.
CAUTION: Toxicity (tachycardia, CNS excitation).
Avoid combination with macrolides and quinolones.
Antidote: activated charcoal
Update: Steroids
> Long term oral use for respiratory disease is rarely indicated ie prednisolone (problems osteoporosis, pain around femoral head, diabetes)
used for acute/standby treatment
Withdraw gradually if: use >3 weeks, >40 mg prednisolone/d
When stepping down use of steroid inhalers: Reduce dose slowly (by 50% every 3 months)
CAUTION: Osteoporotic fractures: Consider bone protection if long term treatment necessary
***Ensure use of steroids aligned with COPD GOLD guideline
Update: Inhalers
> Assess symptom control (SIGN 153 recommends : ask about frequency of inhaler use/adherence)
Effectiveness
Assess inhaler technique and adherence to dosing schedule
Also see NHS Scotland Respiratory Prescribing Strategy.
Better to use some inhalers over others because of their damage to the environment: salamol vs ventolin=>salamol bc contains less amount of propellant gases that are not safe for environment
MHRA Warning
MHRA WARNING –
>PHOLCODEINE WITHDRAWN bc it causes anaphylaxis
>Condeine linctus switched from P to POM bc of abuse
>PSEUDOEPHIDRINE PRODUCTS: sudafed, actifed=>encaphalopathy (affects the brain), PRES=>watch for patients with memory loss, confusion, lack of coordination/balance, n+v, form of brain damage/problems
UPDATED GUIDELINES ON RESPIRATORY SYSTEM DRUG DELIVERY
> Advice to be given to patients
Patients should be advised on how to check the number of medication doses in their inhaler device. For metered-dose inhalers, they should be informed that these inhaler devices deliver a fixed number of medication doses per cannister, and that after these doses have been used up, the inhaler will continue to actuate, expelling propellant gas but no active ingredient. This may lead to patients inadvertently using ‘empty’ inhalers and inhaling propellant only instead of medication, which could lead to exacerbation and destabilization of their condition, as well as unnecessary expulsion of harmful propellant gas into the environment. Some inhalers contain an integrated dose counter which alerts patients to when all therapeutic doses have been used. For inhalers without a dose counter, there is no accurate way to gauge the remaining number of therapeutic doses other than by either recording every actuation used, or by calculating when the inhaler is likely to become ‘empty’ according to their standard usage. Shaking, weighing or floating the inhaler device, or using it until it no longer actuates are not accurate and not recommended.
Patients should also be advised to follow manufacturers’ instructions on the care and cleaning of their inhaler device, and to return empty or expired inhalers to pharmacies for correct disposal (and recycling where available).
For information on inhalers and their environmental impact, see NICE patient decision aid: Asthma inhalers and climate change (see Useful resources).
An 89-year-old patient is receiving end of life medication in a care home. He has been coughing continuously for a week and the doctor would like to prescribe some cough medicine for him. What is the best choice for the doctor to prescribe for this patient?
A. Methadone oral solution
B. Diamorphine oral solution
C. Oxycodone oral solution
D. Morphine oral solution
E. Pholcodine oral solution
D. Morphine oral solution (before was methadone for palliative care)
Ms. D presents symptoms as shown in the picture. Her regular medication include Amlodipine, Clenil inhaler, indapamide, warfarin and metformin. Which of the following is appropriate advice you would give to manage her symptoms?
Select one option below.
A. Drink water before using clenil inhaler.
B. Sell Miconazole oral gel
C. Recommend a spacer
D. Refer patient to her GP
E. Ask patient to reduce dose of her clenil inhaler.
D. Refer patient to her GP (presenting with oral thrush from steroid in Clenil inhaler
spacer: (may prevent from future)
miconazole interacts with warfarin: INR up, increase bleeding
Cough
CAUSES – COPD, Infection, medication (ACE/ARB), Allergy, smoking
Ages – Over 6 years (guafenicine) and under 6 years (5 yrs chesty cough: no medication)
Cough preparations - DRY AND CHESTY (unless systemic: bloody phlegm, yellow/green, struggling to breath) - types of treatment
Expectorants (guafenacine, ipecacuanha), cough suppressants (dextromephan), demulcents (glycerin, honey/lemon, simple linctus: paediatric for 1-11yrs), anti-histamines (to help sleep)
Palliative care – Morphine oral solution
Croup
Croup is a common childhood infection that causes a barking cough and a rasping sound when breathing. Hoarse voice and breathing difficulties.
MILD – Self limiting (cough but able to breath and can carry on with daily activities, no breathing restrictions)=>drink water, rest, take multivitamin
Severe (breathing difficulties, feeling poorly, tired, fatigued) – Refer to gp if able to swallow=> Dexamethasone (STAT dose, immediate, all at once), not able to swallow, send to A/E=> nebulised Budesonide
Life threatening (cannot breath) - must go to A/E=>Adrenaline and Epinephrine
Antihistamines
Sedating and less-sedating
Loratidine 1 OD vs Piriton (chlorphenamine) 1 QDS=> reaction from something eaten, take piriton bc gets into system more often
Side-effects: constipation, dry mouth, blurry vision, drowsiness/dizziness, urinary retention
Choice in elderly (65+): recommend less sedating bc risk of falls
Conditions to consider: for epilepsy (dont sell piriton, sedating AH crosses BBB), renal impairment (dont sell cetirizine, clearance depends on renal excretion, sell loratadine instead), hepatic (dont sell loratadine as metabolised by liver)
Desensitizing vaccines (pt at risk of severe reactions if contact made with allergen): dont give vaccine to asthmatic patients, pts on ACE inhibitor or Beta blockers
An 18-year-old who suffers from chronic asthma is currently on Ventolin 100mcg inhaler QDS PRN (SABA) and Clenil 100mcg inhaler BD. The doctor would like to step up her treatment as her symptoms are not well controlled. Which option is the correct next course of action to take according to BTS?
A. Increase the dose of Ventolin inhaler.
B. Add a LABA
C. Add a LTRA
D. Increase the dose of her ICS
E. Add modified release theophyline
BTS favours LABA > LTRA
B. Add a LABA
Electroysis: Name examples of drugs in chapter 3 that can cause electrolyte imbalance
cause low levels of potassium: SABA (salbutamol, terbutaline), corticosteroids, theophylline
Asthma
> ACUTE and chronic
Reversible (unlike COPD)
Symptoms – coughing at night, wheezing, tight chested, SOB (salbutamol first choice for asthma, must have attacks 3 or more times a week to be prescribed 1-2puffs QDS PRN)
Lifestyle advice: smoking cessation, weightloss, exercise and breathing techniques, avoid substances that trigger asthma
Pregnancy: continue medications as benefits of management outweigh risks until meet with GP
FEV1: spirometer used for spirometry test
NICE guidelines vs BTS guidelines
NICE vs BTS Guidelines
AGE – under 5yrs , over 5yrs and adult
NICE an Adult is over 17years
BTS an adult is over 12 years
**take age into account
NICE guidelines favours early LTRA (montelukast, blocks allergen from binding to receptor) initiation whilst BTS favours early LABA (salmeterol) initiation in adults.
How often should the growth of children on long-term corticosteroid treatment be monitored?
A. Every month
B. Every 6 months
C. Every year
D. Every 2 years
E. Every 5 years
C. Every year (affects bone growth in children)
Asthma
BTS GUIDELINES
OVER 12 YRS AND ADULT; NICE 17yrs
>
- SABA (1st line, 1-2puffs QDS PRN)- salbutamol or terbutaline (brycanyl), give salamol bc environment
add another drug (check inhaler technique and adherence before you add)/stepup treatment if used salbutamol more than 3x’s a week/waking up at night - ICS (low dose ICS, start with 50mcg 1-2puffs BD increase to 100mcg 1-2puffs BD, max)– beclomethasone , budesonide
- Add on LABA (if low dose ICS does not manage) e.g. salmeterol OR ADD MART (MART with SABA, maintenance and reliever treatment, LABA+ICS combo=>Fostair 100/6, 200/6, Symbicort 100/6, 200/6, 400/6)
**Trimbow (3 active ingredients, stored in fridge); NICE Adds LTRA (montelukast 4mg (age 3-5), 5mg (age 5-14), 10mg (15yrs+)) - Increase ICS dose (or MART dose if on MART)
- LTRA OR THEOPHYLINE OR TIOTROPIUM (Spiriva, Braltus); NICE Adds LABA
- Prescreen requires bloodiest checking for TB, must be treated before Monoclonal antibodies (refer to a specialist)
Asthma
BTS GUIDELINES
5 - 12 YRS
- SABA
- ICS Low dose (1-2puffs 50mcg BD, max)
- Add on LTRA or a LABA (BTS: LABA>LTRA); NICE=>LTRA
- Increase ICS dose (1-2 puffs 100mcg BD, max)
- SPECIALIST
- Monoclonal antibodies
Asthma
BTS GUIDELINES; NICE agree
UNDER 5
- SABA
- Low dose ICS (1-2 puffs 50mcg BD, max)
- Add on LTRA (montelukast 4mg as chewable granules)
- Specialist
A 33-year-old patient is experiencing a life-threatening acute asthma attack. Which symptom is mostly associated with life-threatening acute asthma?
A. Inability to complete sentences in one breath.
B. Heart rate >110/min
C. Cyanosis
D. Respiratory rate > 25/min
E. SPO2 > 92%
C. Cyanosis (due to low levels of oxygen, skin starts to turn blue)
***review acute asthma attack, different stages have different symptoms
severe acute asthma symptom: heart rate >110/min, inability to complete sentences in one breath
life-threatening: arrhythmia, exhaustion, cyanosis
Oxygen
> Oxygen should be regarded as a drug. It is prescribed for hypoxaemic patients to increase alveolar oxygen tension and decrease the work of breathing. The concentration of oxygen required depends on the condition being treated; the administration of an inappropriate concentration of oxygen can have serious or even fatal consequences.
Oxygen is probably the most common drug used in medical emergencies. It should be prescribed initially to achieve a normal or near–normal oxygen saturation; in most acutely ill patients with a normal or low arterial carbon dioxide (PaCO2), oxygen saturation should be 94–98% oxygen saturation. However, in some clinical situations such as cardiac arrest and carbon monoxide poisoning it is more appropriate to aim for the highest possible oxygen saturation until the patient is stable. A lower target of 88–92% oxygen (overdose of opioids, Benzos, COPD, cystic fybrosis) saturation is indicated for patients at risk of hypercapnic respiratory failure.
High concentration oxygen therapyis 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.
COPD
Irreversible
Causes: smoking
Lifestyle Advice: smoking cessation, weightloss, exercise, breathing techniques
Vaccinations: encourage influenza vaccine on annual basis (egg allergy gets different vaccine), pneumococcal vaccine (only get vaccine once unless gp advises a boost)
pts over 65: fluad, quadravalent
under 65: trivalent
if patient takes immune suppressant/HIV: live or attenuated=>attenuated
COPD- NICE & GOLD guidelines
> COPD is a heterogenous lung condition characterised by chronic respiratory symptoms due to abnormalities of the airways that cause persistent airflow obstruction.
2 types – Bronchitis and Emphysema
> Symptoms
S.O.B
Chronic cough – up to 8 weeks or more
Phlegm production (carbocisteine)
Respiratory tract infections (common in winter, use prednisolone with antibiotics such as amoxicillin, doxycycline 100mg BD STAT and OD thereafter for pts 18 or more) rescue/standy, pt has one them in case needed (prednisolone and doxy), prophylaxis: azythromicin
Recurrent wheezing
GOLD guidelines
> MEASUREMENTS
FEV1 and FVC (give dose of 400mcg salbutamol 15 min before tests), compares lung function with healthy person
Mmrc
CAT
eCOPD (exacerbation of COPD)
SPIROMETER IS USED TO DIAGNOSE COPD.
WE use these four measurements to place patients in GROUP A, B or E in the Gold ABE assessment tool.
FEV1/FVC ratio of less than 0.7 confirms diagnosis of COPD.
Resources
Gold ABE Assessment Tool: Gold Grade of FEV1: the lower the number, the worst COPD
Modified MRC Dyspnea Scale to deduce what group patient belongs to: Grade 0 is healthy by Grade 4, conditions worsens
CATtm Assessment: questionaire to score severity of symptoms from 0-5, score of 25 or more means pt is struggling
eCOPD- exacerbation of COPD– 2 or more exacerbation leading to hospitalization or 1 or more leading to hospitalisation
PATIENTS WILL BE IN GROUP E
0 – 1 moderate exacerbations not leading to hospitalisation
PATIENTS WILL BE IN GROUP A/B
Treatment: Dysnea (shortness of breath) (LABA or LAMA, LABA/LAMA/MART-anoro elliptic, etc) or Exacerbation (condition has been made worse) patient with infection has more eosinophils in bloods (LABA/LAMA, LABA/LAMA/MART, LABA/LAMA/ICS, ROFLUMISLAST/AZITHROMYCIN)
*Dysnea and Exacerbation at same time, use exacerbation
Mrs. R aged 66-years walk into your clinic for a respiratory check for COPD . You check the % of her predicted FEV1 and your required to grade her according to the GOLD assessment tool. Given that the spirometry measured 51% of predicted FEV1, Her CAT score is 8, MMRC is 1 and no exercebations/ hospitalizations in the last year. which group does Mrs. R fit in ? USE RESOURCE gold guidelines sent to members group.
A. GOLD 1 and group E
B. GOLD 2 and group A
C. GOLD 3 and group A
D. GOLD 4 and group B
E. GOLD 2 and group E
B. GOLD 2 and group A
Mr. Tom is 55-year-old patient who suffers from COPD. He is an ex-smoker who is currently using nicotine patches. He was hospitalized twice last winter due to exacerbations of his COPD. He currently uses salbutamol (SABA), fostair (LABA/ICS) and Tiotropium (LAMA) to manage his condition . His test results reveal that he has a blood eos of 365 and his FEV1 is 69% of predicted FEV1. Using the follow-up pharmacological treatment resource in GOLD guidelines 2023, select the most suitable treatment for Mr. Tom?
A. LABA + ICS + LAMA
B. LABA + LAMA + ICS + ROFLUMILAST
C. LABA ONLY
D. LABA + LAMA + ICS + AZITHROMYCIN
E. LABA + LAMA
D. LABA + LAMA + ICS + AZITHROMYCIN
COPD
> NICE GUIDELINES
1. SABA or SAMA (ipatropium)
2. OPTIMISE RX (adherence, technique)
> PATIENTS WITHOUT ASTHMATIC SYMPTOMS/not steroid responsiveness
3. LABA AND LAMA – Discontinue SAMA
4. Add ICS
> PATIENTS WITH ASTHMATIC SYMPTOMS/steroid responsiveness (ICS comes earlier as pt responds better)
3. LABA and ICS
4. ADD LAMA
