Chapter 3- Respiratory System Flashcards
1
Q
Why’s inhalation method preferred for drug delivery to the respiratory system
A
Drug delivered directly to the airways
The dose required is smaller
Side effects reduced
2
Q
What is complete control of asthma defined as
A
No daytime symptoms
No night time awakening due to asthma
No asthma attacks
No need for rescue medication
No limitation to activity
Normal lung function
3
Q
Treatment ladder recommendations for asthma
A
Intermittent reliever therapy:
Start an inhaled short acting beta2 agonist (salbutamol) to be used PRN for infrequent wheezing
Regular preventer therapy:
A low dose inhaled corticosteroids should be started as maintenance therapy in patients using the SABA regularly, waking up due to asthma or had an attack in the last 2 years
Initial add on therapy:
If not controlled on low ICS a LABA
Additional add on therapy:
If LABA not effective stop. If effective but not enough increase ICS to medium dose or consider a third agent (LTRA, MR theophylline)
ConsiderSwitch to MART (maintenance and reliever therapy) a combination of an ICS a fast acting LABA and a low dose ICS as therapy
If MART not effective use 4 agents: continue on high dose ICS, LABA, and either leukotriene receptor antagonist, long acting muscarinic receptor antagonist or MR theophylline or oral b2 agonist tablet (bambuterol)
Step 5 is oral pred while continuing high dose ICS
4
Q
Which asthmatic medications should be held in pregnancy
A
None
5
Q
What peak flow value indicated normal lung function
A
> 80% predicted or best
6
Q
When can you start to consider decreasing asthmatics treatment
A
When their asthma has been controlled with their current therapy for Atleast 3 months
7
Q
What’s should children be Monitored for when starting a steroid for asthma
A
Growth failure Reduces bone mineral density Adrenal suppression Eyes for cataracts Weight and height for growth
8
Q
Management of a severe asthma attack
A
High flow oxygen to maintain levels between 94-98%
Beta2 agonist administered by an oxygen driven nebuliser
Oral prednisolone once daily for Atleast 5 days or until recovery
Can add the following if no improvement:
- nebulised ipratropium
- IV magnesium sulfate
- IV aminophylline (caution with patients on theophylline)
9
Q
What’s the treatment ladder for COPD
A
Breathlessness and exercise limitation:
- short acting b2 agonist or short acting muscarinic antagonist prn (iprtropium)
Exacerbation or persistent:
FEV1> 50%
-LABA
-LAMA (discontinue SAMA) tiotropium
FEV1< 50%
- LABA + ICS
- LAMA (discontinue SAMA)
Persistent exacerbation:
- LAMA + LABA + ICS
Last resort:
Aminophylline or theophylline with long term oxygen therapy
10
Q
What can reduce mortality risk of COPD
A
Not smoking if a smoker
Weight loss if overweight
Vaccinating against influenza
11
Q
When are mucolytic drugs useful in COPD
A
If it is associated with a productive cough
12
Q
How are COPD flare ups treated
A
Corticosteroids or antibacterial if an infection is suspected
13
Q
What are the most effective SABA and why
A
Salbutamol and terbutaline
As they’re selective unlike ephedrine
14
Q
What are SABA used for
A
Immediate relief of asthma symptoms
15
Q
What’s a risk of using SABA and when is the risk heightened
A
Hypokalaemia
Heightened when used with theophylline, corticosteroids and diuretic
Also worse when patient is hypoxia
16
Q
How long does SABA effects last
A
3-5 hours
17
Q
Give examples of LABA and its use
A
Salmeterol and formoterol
Role in long term control of chronic asthma in patients who regularly use an ICS
(Salmeterol should not be used for acute relief of asthma attack as onset is too slow)
18
Q
How long does LABA effects last
A
Up to 12 hours
19
Q
Side effects of b2 agonists (bronchodilator)
A
Tremor Headache, muscle cramps, palpitations Bronchospasm Tachycardia, arrhythmia MI Sleep disturbances
20
Q
What’s an example of a SAMA
A
Ipratropium
21
Q
Examples of LAMA
A
Tiotropium
Glycopyrronium
Aclidinium
22
Q
How long does SAMA effects last
A
3-6 hours
23
Q
Caution with the use of SAMA and LAMA
A
Prostatic hyperplasia
Bladder outflow obstruction
Angle- closure glaucoma (reported with nebulised ipratropium particularly when given with nebulised salbutamol)
24
Q
Side effects of Antimuscarinic bronchodilators
A
Dry mouth
Constipation, cough
Headache, dizziness
25
What’s the CHM advice for the use of LABA
To be added if control with regular ICS has failed
Not to be initiated in deteriorating asthma
Be introduced at a low dose and the effect properly monitored before considering dose increase
Be discontinued if absence of benefit
Not to be used PRN for exercise unless ICS is also used
Review to step down as soon as appropriate
26
How are corticosteroids effective in asthma
They reduce airway inflammation and hence reduce oedema and secretion of mucus into the airway
27
Examples of inhaled corticosteroids
Beclometasone
Budesonide
Fluticasone
Momentasone
28
How are inhaled corticosteroids effective in COPD
May reduce exacerbation when given in combination with an inhaled LABA
29
Common side effects of ICS
Oral thrush
Altered taste
Voice alterations
LRTI Pneumatic in patients with COPD
30
Why should ICS be prescribed by Brand
They’re not interchangeable
QVAR is twice as potent as Clenil
Forst air is a combination and is also more potent
31
What’s some unlicensed uses of beclometasone
Easyhaler not liveeee for children under 18 year
| QVAR, clenil 200,250 not licensed for children under 12
32
How can Inhaled corticosteroids distinguish between asthma and COPD
If consistent use and improvement over 3-4 weeks, suggests asthma
33
How can you manage oral thrush from the use of ICS
Use spacer
Rinse mouth after
antifungal can be used to treat thrush without stopping treatment
34
How does montelukast work
It blocks the effect of leukotrienes (inflammatory mediators) in the airways
35
Examples of Xanthines
Aminophylline and theophylline
36
How are Xanthines used
Used as Antimuscarinic bronchodilator in asthma and stable COPD (not effective in exacerbation of COPD)
37
When might theophylline have additive effects
When used with beta2 agonists
| Can especially exacerbate hypokalaemia
38
Where is theophylline metabolised and what increased its plasma concentration
Metabolised in the liver.
```
Heart failure
Hepatic impairment
Viral infections
Elderly
Drugs that inhibit it’s metabolism (diltiazem, erythromycin, ciprofloxacin)
```
39
What decreased theophyllines plasma concentration
Smokers
Alcohol consumption
Drugs that induce its metabolism (carbamazepine, primidone, phenytoin and phenobarbital)
40
Theophylline therapeutic range
10-20mg/L
41
How is aminophylline administered
By very slow IV injections over Atleast 20 minutes as it’s too irritant for IM
42
Warning signs for theophylline
Toxicity
| Uncontrolled asthma
43
What needs to be monitored with theophylline
Serum potassium
| Plasma theophylline concentration
44
What’s important about prescribing theophylline and aminophylline
Maintaining the same brand
45
What’s croup and how is it treated
Infection in the upper airway that blocks breathing and causes barking cough
Usually self limiting but can give single dose corticosteroids (dexamethasone)
46
What’s used in asthma management but ineffective in COPD
Leukotriene antagonist
47
What do anti histamines have a role in
```
Nasal allergies
Runny nose (rhinorrhoea)
Rashes
Insect bites
Drug allergies
Nausea and vomiting
Occasional insomnia
```
48
How are the new generations antihistamine different to the older generation and why
Newer cause less sedation and psychomotor impairment because they penetrate the BBB only to a slight extent
49
What’s the first line treatment and route for anaphylaxis reaction
Adrenaline 500micrograms
| Via intramuscular route
50
Same the sedating antihistamines (older gen)
Promethazine
Alimemazine
Chlorphenamine
Hydroxyzine
51
Name the newer non-sedating antihistamines
```
Cetirizine
Fexofenadine
Loratidine
Acrivastine
Desloratidine
Levocetitizine
Mizolastine
```
52
What’s the rare side effect of all antihistamine
```
Hypotension
Palpitation
Arrhythmia
EPSA
Dizziness
Confusion
```
53
What do sedating antihistamines have a significant effect on and when should it be cautioned
Antimuscarinic activity
Cautioned in prostatic hyperteophy, urinary retention and susceptibility to angle-closure glaucoma
54
What symptoms do antihistamines not help with
Nasal congestion
55
Which antihistamine is taken upto 4 times a day
Chlorphenamine
56
When should sedating antihistamines be avoided and why
Liver disease
Risk of coma
57
What should be counselled to be avoided in excess when taking antihistamine
Alcohol
58
What should be given in an anaphylactic/ angioedema reaction
```
Adrenaline/ epinephrine (5minute intervals)
Oxygen
Antihistamine
Corticosteroids
IV fluids
```
59
From what age is chlorphenamine and promethazine licensed to be sold OTC
6 and above
60
What risk is hydroxyzine been associated with and what did the meds review conclude to minimise the risk
Small risk of QT interval prolongation and torsade de pointes
To minimise the side effects the restrictions are:
- contraindicated in patients with or at risk of QT prolongation
- avoid use in elderly
- in adults max daily dose is 100mg, in elderly max daily dose 50mg (if use can’t be avoided)
- in children upto a body weight of 40kg max daily dose is 2mg/kg
- prescribe at lowest affective dose for shortest period of time
61
Name some mucolytics and how are they used in COPD
Carboceisteine
Acetylcysteine
Reduce sputum viscosity and can reduce exacerbation in some COPD patients and people with chronic productive cough
(Therapy should be stopped after 4 weeks with no benefit)
62
What age is aromatic decongestant not advised, what can be carried out instead?
Under 3 months
Sodium chloride nasal drops or sunction aspiration
63
Examples of demulcent preparations and their effect
Glycerol
Simple linctus
Soothing
64
Examples of expectorants and effects
Guaifenesin
Ipecacuanha
Expel bronchial secretions
65
OTC cough preparations should not be sold for children under 6 if they contain what?
Antihistamines
Cough suppressant (eg: pholocodiene)
Expectorants (eg: Guaifenesin)
Decongestants (eg: pseudoephedrine)
66
What’s the duration you can sell OTC cough preparations to 6-12 years old
5 days or less
67
When should decongestants be cautioned and avoided
Cautioned in patients with diabetes, hypertension, hyperthyroidism
Avoided in patients taking MAOIs
68
What’s used as a cough suppressant (antitussive)
Codeine
Pholocodine
Dextromethorphan
69
What PEF would you expect to see for a patient having a severe asthma attack
33%-50%
70
How is asthma diagnosed
Presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough)
And variable airflow obstruction
71
How should patients ICS be decreased
25-50% every 3 months to the lowest effective dose
72
Symptoms of moderate acute asthma attack
PEF 50-75
| Increasing symptoms
73
Symptoms of acute severe asthma attack
PEF 33-50
RR >25/min
HR >110/min
Can’t complete sentences in one breath
74
What does Fostair contain
Beclometasone and formoterol
75
What does spiromax and symbicort contain
Budesonide and formoterol
76
What does seretide contain
Fluticasone and salmeterol
77
Why should salmeterol not be used for the acute relief or prevention of exercise induced asthma
Long onset of action
78
Which ICS can be taken once daily
Ciclesonide
| Momentasone
79
What is aminophylline a mixture of
Theophylline and ethylenediamine
80
When should theophylline be sampled after dose
4-6 hours
81
What’s the oxygen therapy for severe COPD with hypoxaemia
15 hours a day or more
88-92% O2 saturation
Must carry O2 alert card and use a 24% or 28% Venturi mask of history of hypercapnia respiratory failure
82
How should self administered adrenaline be used
2 carried at all times
Administer mid point of outer thigh
Second injection 5-15 minutes after first injection
Call ambulance if symptoms don’t improve
Lie down and raise legs (sit up if difficulty breathing)
83
Adrenaline autojector dose
Adult= 300-500mcg
| Child 15-30kg= 150mcg
84
Contraindications for mucolytics
Active peptic ulceration as it disrupts gastric mucosa
85
What electrolyte disturbance can occur with the coadministration of salbutamol and theophylline
Hypokalaemia
86
When do you check theophylline doses when starting and after dose changes
5 days after starting
3 days after dose change
87
Signs of theophylline toxicity
Vomiting and GI effects
Tachycardia
Arrhythmia, convulsion and hypokalaemia
88
What medication should daktarin gel (miconazole) not be taking with
Warfarin
89
How can you manage mild bronchospasm from ICS
Use SABA beforehand
| Transfer pMDI to dry powder inhaler
90
What dose of prednisone would you expect to see for the treatment of an acute asthma attack in an adult
40-50mg for 5 days
Child under 12: upto 3 days
91
Why electrolyte disturbance is caused from SABA and LABA
Hypokalaemia
92
What electrolyte disturbance can potentially occur with co administration of theophylline and salbutamol
Hypokalaemia
93
What PEF would be expected for an adult who is defined as having a severe asthma attack
33-50%
94
Theophylline side effects
```
Arrhythmia
CNS stimulation
Convulsions
Diarrhoea
GI irritation
Headache
Insomnia
Palpitation
Tachycardia
Vomiting
```
95
How do you inhale steroid inhalers?
Quick and deep
96
What PEF would you expect to find for an adult who is defined as having moderate asthma attack
50-75%
97
Who should be given oral prednisolone with asthma
Anyone who’s had an asthma attack
| Minimum 5 days
98
There’s an increased risk of of hypokalaemia when theophylline is taken with which drugs
LOOP diuretics
Thiazide diuretics
Corticosteroids
B2 agonist
99
How should ICS initially be used when starting
Twice daily (except ciclesonide)
100
What condition should beta 2 agonist be cautioned with
Diabetes
101
What inhalvers have extra fine particles
QVAR
| Fostair
102
When should a large volume spacer be used
High dose ICS
| Patients under 15
103
Why might smokers need a higher ICS dose
Current and ex smokers reduces effectiveness of ICS so might need a higher dose
104
What’s the dose for SAMA
TDS
105
What’s the dose of LAMA
OD (except Eklira BD)
106
What steroid dose would you give for a COPD exacerbation
30mg OD for 7-14 days
107
What’s the most sedating old antihistamine
Promethazine
| Alimemazine
108
Which antihistamine causes QT prolongation
Hydroxyzine
109
What’s an nsaid antihistamine
Ketotifen
110
How do decongestants work and when should they be avoided
Narrow blood vessels to reduce inflammation
```
Avoided in:
Heart problems
High blood pressure
Overactive thyroid
Diabetes
Pregnant women
```
111
How long can nasal decongestant be used and why
No longer than 7 days
Causes rebound congestion
112
What time should decongestants not be taken and why
Night
They have a stimulant effect
113
Why’s the sale of pseudoephedrine monitored
Aj be used to make methylamphetamine
114
What meds should be used for productive cough and which for non productive cough
Productive: expectorants (guaifenesin)
Non productive: suppressant (codeine, pholocodeine, dextromethorphan)
115
What antihistamine can be used to reduce a cough
Diphenhydramine
116
What’s the sale limit for products containing pseudoephedrine or epherdine to a person at one time in one transaction
720mg of pseudoephedrine
| 180mg of ephedrine
117
What inhalants can be used OTC to help clear catarrh
Menthol, pine oil eucalyptus
118
When to refer colds and flus
Earache not settling with analgesic
Facial pain or frontal headache
Very young
Very old
Heart or lung disease
With persistent fever and productive cough
Chest pain
Delirium
At risk patients (high BP, diabetics, asthmatics)
No improvement after 14 days of self medication
119
When to refer coughs
```
Lasting > 2 weeks
Colour sputum
Chest pain
Shortness of breath
Wheezing
Whooping cough or croup
Failed medication
Recurrent night time coughing
```
120
Sore throat OTC treatment options
Simple analgesic
Flubiprofen- NSAID lozenges
Difflam- NSAID
Tyrothricin- antibiotic lozenges
Local anaesthetic- dumbing effect
Demulcent pastilles- lubricating effect
121
When to refer for sore throats in a community setting
```
Sore throat lasting more than a week
Recurrent blunts of infection
Hoarseness for more that 2 weeks
Difficulty swallowing
Failed medication
Carbimazole patients
```
122
What age is steroid nasal sprays licensed to be sold otc
18+
123
OTC products available for topical decongestant
Xylometazoline
| Oxymetazoline
124
What’s the first line OTC antihistamine for hayfever
Loratidine as it’s least likely to cause sedation
125
What age are nasal decongestant like xylometazoline and oxymetazoline licensed to be sold OTC
12
126
Why should decongestant be avoided in a few conditions
They increase blood sugar levels, heart rate and muscle tremor
127
Whats the best assessment for asthma control
Symptoms
128
What age can peak flow meters be used from
5
129
How should aminophylline be administered for severe acute asthma
5mg/ kg
| Over 20 minutes
130
What does drying a spacer with a cloth do
It increases the chances of electrostatic charges
131
What are alternatives for SABA
SAMA- ipratropium
If 12+ years- theophylline or oral b2 agonist (bambuterol)
132
With asthma treatment, what symptoms will prompt you to step up
Symptoms 3 times a week
Night time symptoms once a week
Asthma attack requiring systemic steroids in last 2 years
Refer if using >1 inhaler a month, not wel controlled
133
When should you advice the patient to see the gp if a Saba fails to provide relief for a certain length of time
< 3 hours
134
What brands contain formoterol
Fostair
Duoresp
Spiromax
Symbicort (18+)
135
What’s the order of potency in beclometasone inhalers
Fostair (most)
Qvar
Clenil
Other CFC containing beclometasone (least)
136
What should you do if paradoxical bronchospasm is experienced from ICS
Stop and give alternative
137
What group of patients might need a higher dose of ICS and why
Current and previous smokers
As it reduced effectiveness of ICS
138
What are used of LRTI
Chronic asthma
| Symptomatic relief of hay fever in asthma
139
Side effect of LRTI
Churg strauss syndrome- occurs on withdrawal of oral corticosteroids
Zafirlukast (liver toxicity)
140
When what drugs are given with theophylline it increases risk of hypokalaemia
Loop or Thiazide diuretics
Corticosteroids
B2 agonist
141
What does theophylline interact with to increase risk of seizures
```
Ciprofloxacin
Quinolone (lowers seizure threshold)- Pd interaction
```
142
Example of enzyme inhibitor that increase theophylline levels
Quinolones - pk interaction
143
What medication causes an increase plasma concentration of theophylline and risk of toxicity
```
Verapamil/ calcium channel blocker
Cimetidine
Phenytoin
Fluconazole
Macrolides
```
(All enzyme inhibitors)
144
What medication causes a decrease in plasma concentration of theophylline and is subtherapeutic
St. John’s wort
| Rifampicin
145
Which LAMA can be used in asthma with 1 or more severe exacerbation in the last year
Tiotropium (spiriva respimat)
146
Uses of antihistamines
Allergies (nasal and skin)
Nausea and vomiting
Insomnia
Emergency anaphylaxis and angioedema
147
What is allergen immunotherapy and who should it be avoided in
When the patient is exposed to the exact thing they are allergic to to make the desensitised
```
Avoided in
Asthmatic
Pregnant women
Children under 5
People on BB
people on ACEi
```
148
What’s the safety concerns regarding desensitising vaccines
Hypersensitivity reactions
Life threatening bronchospasm and anaphylaxis
Must be monitored for 1 hour and cpr readily available
149
How does adrenaline help on an anaphylaxis reaction
Dilates the lungs to open airways
Constricts vessels to increase BP
150
Should an ambulance be called if an adrenaline auto injector is administered and they improve
Yes
Should always call an ambulance so they can be monitored
151
What can IV salbutamol cause
Hyperglycaemia
152
How many cigarettes a day does someone need to smoke to be given the higher dose patch
10+
153
How many cigarettes a day does someone need to smoke to be given the higher dose patch
10+
154
How long should a child stay home with whooping cough
3 weeks after cough started
| 5 days after started antibiotics
