Respiratory Flashcards
(152 cards)
1
Q
AAFB
A
Acid and Alcohol Fast Bacili
2
Q
ABPA
A
Allergic Bronchopulmonary Aspergilosis
3
Q
BIPAP
A
Bilevel Positive Airway Pressure
4
Q
CPAP
A
Continuous Positive Airways Pressure
5
Q
EAA
A
Extrinsic Allergic Alveolitis
6
Q
ICD
A
Intercostal Chest Drain
7
Q
ILD
A
Interstitial Lung Disease
8
Q
INH
A
Inhaled
9
Q
LTOT
A
Long Term Oxygen Therapy
10
Q
MCL
A
Mid-Clavicular Line
11
Q
NIV
A
Non-Invasive Ventilation
12
Q
PEFR
A
Peak Expiratory Flow Rate
13
Q
PFT’s
A
Pulmonary Function Tests
14
Q
PND
A
Paroxysmal Nocturnal Dyspnoea
15
Q
SVCO
A
Superior Vena Cava Obstruction
16
Q
UIP
A
Usual Interstitial Pneumonia
17
Q
Define vital capacity
A
Volume of air expired from the lungs from a maximal inspiration using a slow/relaxed manoeuvre
18
Q
Define forced vital capacity
A
Volume of air than can be forcibly expelled from the lungs from a position of maximal inspiration
19
Q
Define forced expiratory volume
A
Volume of air forcibly expelled from the lungs in the first second - following maximal inspiration
20
Q
Define FEV1/FVC
A
Volume of air forcibly expired in the first second as a percentage of the total volume exhaled
21
Q
Obstructive vs Restrictive spirometry
A
Obstructive - smooth curve reaching close to normal volume over a longer period of time
Restrictive - plateaus at a lower than normal volume
22
Q
Early small airways obstruction on volume flow chart
A
Slight depression
23
Q
Chronic obstructive diseases on volume flow chart
A
Large depression
24
Q
Fixed large airway obstruction of volume flow chart
A
Circular
25
Restrictive disease on volume flow chart
Normal height but very narrow
26
Causes of low paO2
Hypoventilation
Diffusion impairment
Shunt
V/Q mismatch
27
Causes of respiratory acidosis
Hypoventilation
- neuromuscular diseases
Alveolar hypoventilation
- COPD
28
Define A-a gradient
A=alveolar
a= arterial
Difference between oxygen concentration in the alveoli and arterial system
29
How to calculate A-a gradient
PAO2 = PIO2 - PaCO2/0.8
PIO2 = room air (20kPa)
30
Normal A-a gradient
Young healthy people - less than 2kPa
Older people - less than 4kPa
> 4 = lung pathology
31
Define anaphylaxis/angioedema
```
Serious allergic reaction
Occurs when sensitised individual exposed to specific antigen
- insects bites/stings
- food
- medications
```
32
Pathophysiology of anaphylaxis
Immunological response
| IgE -> Antigen -> mast cell and basophils -> histamine increases -> body response
33
Clinical features of anaphylaxis
Occurs in minutes
- pruritus, urticaria, angioedema, hoarseness
Progresses to
- stridor and bronchial obstruction, wheeze and chest tightness from bronchospasm
34
Treatment for anaphylaxis
Remove trigger, maintain airway - 100% O2
IM adrenaline 0.5 mg
IV hydrocortisone 200 mg
IV chlorpheniramine 10mg
If hypotensive - lie flat and fluid resuscitate
Bronchospasm - NEB salbutamol
Laryngeal oedema - NEB adrenaline
35
Features of mild asthma attack
No features of severe asthma
| PEFR > 75%
36
Features of moderate asthma attack
No features of severe asthma
| PEFR 50-75%
37
Features of severe asthma attack
PEFR 33-50% of best or predicted
Cannot complete sentences in 1 breath
RR > 25/min
HR > 110/min
38
Features of life-threatening asthma attack
PEFR < 33% of best or predicted
Sats < 92% or ABG pCO2 < 8kPa
Cyanosis, poor respiratory effort, near or fully silent chest
Exhaustion, confusion, hypotension or arrhythmias
Normal pCO2
39
Features of near fatal asthma attack
Raised pCO2
40
Acute asthma management
ABCDE
Aim for SpO2 94-98% with oxygen as needed - ABG if sats < 92%
5mg nebulised salbutamol - repeat after 15 mins
40mg oral Prednisolone STAT - IV hydrocortisone if PO not possible
If severe
- nebulised Ipratropium Bromide 500mg
- back to back salbutamol
If life threatening or near fatal
- urgent ITU or anaesthetist assessment
- urgent portable CXR
- IV aminophyline
- IV salbutamol if nebulised route ineffective
41
Features of COPD exacerbations
```
Infective
- change in sputum volume / colour
- fever
- raised WCC +/- CRP
Non-infective
```
42
Management of COPD exacerbations
ABCDE approach
Oxygen
- via fixed performance face mask due to risk of CO2 retention
- aim for SaO2 88-92% - guided by ABGs
NEBs - salbutamol and Ipratropium
Steroids - Prednisolone 30mg STAT and OD for 7 days
Antibiotics if raised CRP / WCC or purulent sputum
CXR
IV aminophylline
NIV if type 2 respiratory failure and pH 7.25-7.35
If pHh <7.25 consider ITU referral
43
Features of pneumonia
Consolidation on CXR with fever +/- purulent sputum +/- raised WCC and/or CRP
44
Management of pneumonia
ABCDE
If features of sepsis - immediately treat using sepsis pathway
Treat with antibiotics as per CURB-65 score
45
How to calculate CURB-65 score
```
1 point for
Confusion
Urea - > 7.0mmol/L
RR > 30
BP < 90 mmHg
Aged over 65
```
46
Definition of massive haemoptysis
> 240mls in 24 hrs
| > 100mls/day over consecutive days
47
Management of massive haemoptysis
ABCDE
Lie patient on side of suspected lesion
Oral tranexamic acid for 5 days - or IV
Stop NSAIDs / aspirin / anticoagulants
Antibiotics if evidence of respiratory tract infection
Consider vitamin K
CT aortogram - bronchial artery embolisation
48
Features of tension pneumothorax
Hypotension
Tachycardia
Deviation of trachea away from side of pneumothorax - x-ray
Mediastinal shift away from pneumothorax
49
Management of tension pneumothorax
Large bore IV cannula into 2nd ICS MCL
| Chest drain into affected side
50
Symptoms of PE
Chest pain - pleuritic
SOB
Haemoptysis
Low cardiac output followed by collapse
51
Risk factors for PE
```
Surgery
- abdo/pelvic
- knee/hip replacement
- post-op ITU
Lower limb
- fracture
- varicose veins
Malignancy
- abdo/pelvis/advanced/metastatic
Reduced mobility
Previous proven VTE
```
52
Management of PE
```
ABCDE
Oxygen if hypoxia
Fluid resuscitation - if hypotensive
Thrombolysis considered if massive PE confirmed on echo or CT
- check for contraindications
Fully anticoagulated
```
53
Features of a massive PE
Hypotension/imminent cardiac arrest
Signs of right heart strain on CT/echo
Consider thrombolysis with IV alteplase
54
Thrombolysis contraindications
```
Absolute
- haemorrhagic stroke or ischaemic stroke < 6 months
- CNS neoplasia
- recent trauma or surgery
- GI bleed < 1 month
- bleeding disorder
- aortic dissection
Relative
- warfarin
- pregnancy
- advanced liver disease
- infective endocarditis
```
55
Thrombolysis complications
```
Bleeding
Hypotension
Intracranial haemorrhage/stroke
Reperfusion arrhythmias
Systemic embolisation of thrombus
Allergic reaction
```
56
Characteristics of asthma
Chronic inflammatory disease of the airways
Airway obstruction that is reversible - spontaneously or with treatment
Increased airway responsiveness to a variety of stimuli
57
Wheeze differentials
Acute asthma exacerbation
Bronchitis - viral or bacterial
Pulmonary oedema
PE
58
Asthma pathophysiology
Airway epithelial damage - shedding and sub epithelial fibrosis, basement membrane thickening
Cytokines amplify inflammatory response
Increased numbers of mucus secreting goblet cells and smooth muscle hyperplasia and hyper trophy
Mucus plugging - fatal and severe asthma
59
Inflammatory cells involved in asthma reactions
Eosinophils
Th2 lymphocytes
Mast cells
60
Inflammatory mediators released in asthma
Histamine
Leukotrienes
Prostaglandins
61
Criteria for safe asthma discharge after exacerbation
PEFR > 75%
Stop regular nebulisers for 24 prior to discharge
Inpatient asthma nurse review to reassess inhaler technique and adherence
Provide PEFR meter and written asthma action plan
At least 5 days oral Prednisolone
GP follow up within 2 working days
Respiratory clinic follow up within 4 weeks
Consider psychosocial factors for severe or worse
62
Differentials for eosinophilia
```
Airway inflammation - asthma or COPD
Hay fever / allergies
Allergic Bronchopulmonary Aspergilosis
Drugs
Vasculitis
Eosinophilia pneumonia
Parasites
Lymphoma
SLE
Hypereosinophilic syndrome
```
63
Triggering factors for asthma
```
Smoking
Upper respiratory tract infections - mainly viral
Allergens
- pollen
- house dust mite
- pets
Exercise
Occupational irritants
Pollution
Drugs
- aspirin
- beta blockers
Food and drinks
- dairy produce
- alcohol
- orange juice
Stress
For severe asthma consider
- inhaled heroin
- pre-menstrual
- psychosocial aspects
```
64
Steps for a chronic asthma appointment
Use BTS stepwise management guidelines
Assess and teach the inhaler technique
Use self management plans
Avoid trigger factors
65
COPD definition
Characterised by airflow obstruction
- progressive
- not fully reversible
- does not change markedly over several months
66
Pathophysiology of COPD
Umbrella term which encompasses emphysema and chronic bronchitis
Mucous gland hyperplasia
Loss of cilial function
Emphysema - alveolar wall destruction causing irreversible enlargement of air spaces distal to the terminal bronchioles
Chronic inflammation - macrophages and neutrophils
Fibrosis of small airways
67
Causes of COPD
Smoking
Inherited α-1-antitrypsin deficiency
Industrial exposure
68
Outpatient COPD management
```
COPD care bundle
Smoking cessation
Pulmonary rehabilitation
Bronchodilators
Antimuscarinics
Steroids
Mucolytics
Diet
LTOT and lung volume reduction if appropriate
```
69
Criteria for long term oxygen therapy
pO2 consistently below 7.3 kPa or below 8 kPa with cor pulmonale
Non-smokers
Not rents in high levels of CO2
70
Features of LTOT
Continuous oxygen therapy for most of the day - at least 16hrs for survival benefit
Extended periods of hypoxia cause renal and cardiac damage - prevented by LTOT
O2 needs balanced with loss of independence and reduced activity which may occur
71
Features of pulmonary rehabilitation
Many COPD patients avoid exercise and physical activity because of breathlessness
Leads to a vicious cycle of increasing social isolation and inactivity leading to worsening of symptoms
Pulmonary rehabilitation aims to break this cycle - MDT 6-12 week programme of supervised exercise, unsupervised home exercise, nutritional advice and disease education
72
CXR consolidation differentials
```
Pneumonia
TB - usually upper lobe
Lung cancer
Lobar collapse - blockage of bronchi
Haemorrhage
```
73
Management of community acquired pneumonia
Prompt assessment and CXR on admission - consolidation
FBC, U&Es, CRP and sputum culture
CURB-65 score to guide management
No delay in initiating antibiotics +/- paracetamol
ITU referral if high CURB-65 score
74
Pneumonia follow up involves
```
HIV test
Immunoglobulins
Pneumococcal IgG serotypes
Haemophilia us influenzae b IgG
Follow up clinic in 6 weeks with repeat CXR to ensure resolution
```
75
Causes of non-resolving pneumonia
C - complication - empyema, lung abscess
H - host - immune compromised
A - antibiotic - inadequate dose, poor oral absorption
O - organism - resistant or unexpected organism not covered by empirical antibiotic
S - second diagnosis - PE, cancer, organising pneumonia
76
Clinical features of TB
Fever and nocturnal sweats - drenching
Weight loss - weeks-months
Malaise
Respiratory TB - cough, purulent sputum/haemoptysis, pleural effusion
Non-respiratory TB - Erythema nodosum, lymphadenopathy, bone/joint, abdo, meningitis, genitourinary, military, pericardial effusion
77
TB risk factors
```
Past history of TB
Known history of TB contact
Born in country with high TB incidence
Evidence of immunosuppression
- IVDU
- HIV
- solid organ transplant recipients
- renal failure/dialysis
- malnutrition/low BMI
- DM
- alcoholism
```
78
Management of respiratory TB
ABCDE approach and aim to culture
Admit to side room and start infection control
Routine bloods and HIV test and vitamin D levels
CT chest if clinical features/CXR not typical
MRI brain/spine if miliary
If pt critically unwell and high likelihood of TB starts anti-TB therapy after sputum samples sent
Notify TB nurse specialists - support, public health issues and initiate contact tracing
TB culture can take 6-8 weeks - treatment depends on clinical suspicion
79
Basics of anti-TB therapy
Rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 4 months
Ethambutol - 4 months
Check LFTs
Dose is weight dependent
Directly observed therapy (DOT) sometimes used as compliance is crucial
Pt awareness of common and serious side effects
Pyridoxine given as prophylaxis against peripheral neuropathy
80
Major side effects of TB treatment
Rifampicin
- hepatitis, rashes, febrile reaction, orange/red secretions, many drug interactions including warfarin and OCP
Isoniazid
- hepatitis, rashes, peripheral neuropathy, psychosis
Pyrazinamide
- hepatitis, rashes, vomiting, arthralgia
Ethambutol
- retrobulbar neuritis
81
Features of bronchiectasis
Chronic dilation of one or more bronchi
- bronchi exhibit poor mucus clearance
- predisposition to recurrent or chronic bacterial infection
Gold standard diagnostic test = high resolution CT
82
Causes of bronchiectasis
Post-infective - whooping cough, TB
Immune deficiency - hypogammaglobulinaemia
Genetic/much ciliary clearance defects - cystic fibrosis, Young's syndrome, Kartagener syndrome
Obstruction - foreign body, tumour, extrinsic lymph node
Toxic insult - gastric aspiration, inhalation of toxic chemicals
Allergic Bronchopulmonary Aspergilosis
Secondary immune deficiency - HIV, malignancy
Rheumatoid arthritis
Associations - IBD, yellow nail syndrome
83
Bronchiectasis common organisms
```
Haemophilus influenzae
Pseudomonas aeruginosa
Moraxella catarrhalis
Stenotrophomonas maltophilia
Fungi - aspergillus, candidia
Non-tuberculous mycobacteria
```
84
Bronchiectasis management
Treat underlying cause
Physiotherapy - mucus clearance
Antibiotics according to sputum culture/sensitivities for acute exacerbations and chronic suppressive therapy
Supportive - flu vaccine, bronchodilators
Pulmonary rehab
85
Cystic fibrosis definition
Autosomal recessive disease leading to mutations in cystic fibrosis transmembrane conductance regulator (CFTR)
Multi system disease characterised by thickened secretions
86
Criteria for CF diagnosis
One or more characteristic phenotypic features
- or history of CF in sibling
- or positive newborn screening test result
And
- increased sweat chloride concentration - > 60 mol/L Sweat Test
- or identification of two CF mutations - genotyping
- or demonstration of abnormal nasal epithelial ion transport
87
CF presentations
Meconium ileus
- newborn bowel blocked by sticky secretions
- signs of intestinal obstruction soon after birth with bilious vomiting, abdominal distention and delay in passing meconium
Intestinal malsorption
- mostly evident in infancy
- severe deficiency of pancreatic enzymes
Recurrent chest infections
Newborn screening
88
Common complications of CF
Respiratory infections
- needs aggressive therapy with physio and antibiotics
- often receive prophylactic antibiotics
Low body weight
- careful monitoring
- pancreatic enzyme replacement therapy
- high calorie intake and extra supplements
- NG or PEG feeding
Distal intestinal obstruction syndrome (DIOS)
- faecal obstruction in ileocaecum
- often due to insufficient prescription of pancreatic enzymes or non-compliance, salt deficiency or hot weather
- presents with palpable right iliac fossa mass
CF related diabetes
89
CF lifestyle advice
No smoking
Avoid other CF patients
Avoid friends/relatives with colds/infections
Avoid jacuzzis (pseudomonas)
Clean and dry nebulisers thoroughly
Avoid stables, compost or rotting vegetation - risk of aspergillus fumigatus inhalation
Annual influenza immunisation
Sodium chloride tablets in hot weather/vigorous exercise
90
Define pneumothorax
Air in pleural cavity
91
Define pleural effusion
Fluid in pleural cavity
92
Define empyema
Infected fluid in pleural cavity
93
Define pleural plaques
Discrete fibrous areas
94
Define pleural thickening
Scarring/calcification causing thickening
95
Types of pneumothorax
```
Spontaneous
Primary - no lung disease
Secondary - lung disease
Traumatic
Tension
Iatrogenic
```
96
Pneumothorax risk factors
```
Pre-existing lung disease
Height
Smoking/cannabis
Diving
Trauma/chest procedure
Association with other conditions - Marfan's syndrome
```
97
Pneumothorax management
Primary
- if symptomatic of >2cm of air on CXR - give O2 and aspirate
Secondary
- lower threshold for ICD
If persistent air leak > 5 days refer to thoracic surgeons
Discharge advice - no flying or diving until resolved
98
Pleural effusion approach
Hx + Ex
CXR
ECG
Bloods - FBC, U+Es, LFTs, CRP, bone profile, LDH, clotting
Echo - suspected heart failure
Staging CT with contrast - if suspected exudate with cause
99
Pleural effusion diagnosis
```
USS guided pleural aspiration
- biochemistry - protein, pH, LDH
- cytology
- microbiology - AAFB
Consider thoracoscopy or CT pleural biopsy for new effusion
```
100
Causes of transudate effusions
```
Heart failure
Cirrhosis
Hypoalbuminaemia - nephrotic syndrome or peritoneal dialysis
Hypothyroidism
Mitral stenosis
PE
SVCO
```
101
Management of transudate effusions
Often no diagnostic tap required
Treat underlying cause
- stop or reduce treatment if effusion resolves
- if effusion persisted then therapeutic aspiration/drainage required
102
Criteria for exudate effusion
Pleural protein > 30 g/L
103
Causes of exudate effusions
```
Malignancy
Infection
- parapneumonic, TB, HIV
Inflammatory
- RA, pancreatitis, benign asbestos effusion, PE
```
104
Define Light's criteria
If pleural fluid protein level between 25 and 35 g/L exudate if one or more of the following
- pleural fluid protein/serum protein > 0.5
- pleural fluid LDH/serum LDH > 0.6
- pleural fluid LDH > 2/3 upper limit of normal
105
Define interstitial lung disease (ILD)
Umbrella term describing a number of conditions that affect the lung parenchyma in a diffuse manner
- usual interstitial pneumonia (UIP)
- non-specific interstitial pneumonia (NSIP)
- extrinsic allergic alveolitis
- sarcoidosis
106
Clinical features of UIP
Clubbing
Reduced chest expansion
Fine inspiratory crepitations - best heard basal/axillary areas
Features of pulmonary hypertension
107
Cause of UIP
Idiopathic
108
Pathophysiology of extrinsic allergic alveolitis
Inhalation of organic antigen to which the individual has been sensitised
109
Clinical presentation of extrinsic allergic alveolitis
```
Acute
- short period from exposure - 4-8hrs
- reversible
- spontaneously settles 1-3 days
- can recur
Chronic
- chronic exposure
- less reversible
```
110
Define sarcoidosis
Multi system inflammatory condition of unknown cause
Non-caseating granulomas
Immunological response
50% get spontaneous remission, others get progressive disease
111
Investigations for sarcoidsos
```
PFTs - fibrosis
CXR - 4 stages
Bloods - renal function, ACE, calcium
Urinary calcium
Cardiac involvement - ECG, 24 tape, ECHO, cardiac MRI
CT/MRI head - headaches - neuro sarcoid
```
112
ILD treatment principles
```
Depends on underlying pathology
Occupational exposure - remove
Drug associated - avoid
Stop smoking
Transplantation
Treatment of infections
Oxygen
MDT
Palliative care
```
113
Clinical features of lung cancer
Asymptomatic - incidental finding
Any respiratory symptom/systemic deterioration
SVCO
Horner's syndrome
Metastatic disease - liver, adrenals (Addison's), bone, pleural, CNS
Paraneoplastic - clubbing, hypercalcaemia, anaemia, SIADH, Cushing's syndrome, thrombo-embolic disease
114
Risk factors for lung cancer
```
Large number of smoking pack years
Airflow obstruction
Increasing age
Family history
Exposure to other carcinogens - asbestos
```
115
Diagnostic tests for lung cancer
Bloods - FBC, U&Es, calcium, LFT's, INR
CXR
Staging CT - spiral CT thorax and upper abdo
Histology
- US guided neck node FNA for cytology
- bronchoscopy
- CT biopsy
- thoracoscopy
PET scan - helps detect small metastasis not seen on staging CT
116
Histological classification of lung cancer
```
Small cell lung cancer
Non-small cell lung cancer
- squamous cells
- adenocarcinoma
- large cell carcinoma
- bronchoalveolar cancer
```
117
Principles of lung cancer treatment
Curative surgery for stages I and II
Surgery and adjuvant chemotherapy clinical trial for stage IIIa
Chemotherapy - stage III/IV and PS 0-2
Radiotherapy - curative for those not fit for surgery
Palliative care
Watch and wait
118
SCLC treatment
Rapid growth rate and extensive spread at time of diagnosis for surgery
Chemotherapy mainstay
Palliative radiotherapy
119
Define obstructive sleep apnoea (OSA)
Upper airway narrowing provoked by slept causing sufficient slept fragmentation to result in significant daytime symptoms - excessive sleepiness
Due to small pharyngeal size or excessive narrowing occurring with relaxation
120
Causes of small pharyngeal size
Fatty infiltration of pharyngeal tissues and external pressure from increased neck fat and/or muscle bulk
Large tonsils
Craniofacial abnormalities
Extra sub mucosal tissue - myxoedema
121
Causes of excessive narrowing of airway during sleep
Obesity enhance residual muscle dilator action
Neuromuscular disease with pharyngeal involvement may lead to greater loss of dilator muscle tone - stroke, MND, myotonic dystrophy
Muscle relaxants - sedatives, alcohol
Increasing age
122
Clinical effects of OSA
Excessive daytime sleepiness
Rise in daytime BP
Nocturia
Snoring and apnoea attacks witnessed by partner
123
Features of epworth sleepiness scale
Points for following - 0=never would dose, 1=slight chance, 2=moderate chance, 3=high chance
- sitting and reading
- watching TV
- sitting in public place
- passenger in car for an hour
- lying down to rest in the afternoon
- sitting and talking
- sitting quietly after lunch without alcohol
- in car whilst stopped in traffic
124
Diagnosis of OSA
Overnight oximetry alone
125
Management of OSA
Treatment given based on symptoms/QoL
Weight loss, sleep decubitus rather than supine, avoid/reduce evening alcohol intake
Snores and mild OSA - Mandible advancement devices, consider pharyngeal surgery
Significant OSA - nasal CPAP, gastroplasty/bypass
Severe OSA and CO2 retention - NIV prior to CPAP if acidotic
126
Features of CPAP
Usually given via nasal mask
Upper airways splinted open with 10cm H2O pressure - prevents airway collapse, sleep fragmentation and daytime somnolence
Opens collapsed alveoli and improves V/Q matching
127
Examples of sympathomimetics
```
Short acting
- Salbutamol
- Terbutaline
Long acting
- Formeterol
- Salmeterol
```
128
Indications of sympathomimetics
Bronchospasm
129
Action of sympathomimetics
β2-selective adrenergic agonists
| - increase cAMP in SMCs resulting in relaxation thus bronchodilation
130
Metabolism of sympathomimetics
Metabolised - liver
| Excreted - urine
131
Side effects of sympathomimetics
```
Tremor
Headache
GI upset
Palpitations
Tachycardia
Hypokalaemia
```
132
Examples of antimuscarinics
Short acting
- Iptropium
Long acting
- Tiotropium
133
Indications for antimuscarinics
Bronchospasm - typically COPD
134
Action of antimuscarinics
Muscarinic antagonist
| - decreases cGMP which affects the intra cellular calcium -> decreased SMC contractility
135
Metabolism for antimuscarinics
Metabolised - partially in the liver
| Excreted - urine
136
Common side effects of antimuscarinics
Dry mouth
Constipation
Cough
Headache
137
Examples of xanthines
Aminophylline
| Theophylline
138
Main indications for xanthines
Asthma
| COPD
139
Action of xanthines
Block phosophodiesterases -> decreased cAMP breakdown -> bronchodilation
140
Metabolism of xanthines
Metabolised - liver
| Excreted - urine
141
Common side effects of xanthines
```
Headache
GI upset
Reflux
Palpitations
Dizziness
```
142
Other effects of xanthines
Positive chronotropic and inotropic effects
| Diuretic action
143
Therapeutic window of xanthines
```
Plasma level 10-20 mg/L
Toxic effects are serious
- arrhythmias
- seizures
- N+V
- hypotension
```
144
Examples of inhaled glucocorticoids
Beclomethasone
Budesonide
Fluticasone
145
Indications for inhaled steroids
Asthma
| COPD
146
Actions of inhaled steriods
Increases airway calibrate by decreasing bronchial inflammation +/- modifying allergic reactions
Weak mineralcorticoid activity
147
Metabolism of glucocorticoids
Metabolised - liver
| Excreted - urine
148
Side effects of inhaled glucocorticoids
Cough
Oral thrush
Unpleasant taste
Hoarseness
149
Examples of glucocorticoids
Prednisolone - PO
Hydrocortisone - IV/IM
Dexamthasone - PO/IV
Triamcinolone - IM
150
Actions of glucocorticoids
Alters gene transcription
Anti-inflammatory, immunosuppressive, increased gluconeogenesis, decreased glucose utilisation, increased protein catabolism
151
Common side effects of non-inhaled glucocorticoids
```
Adrenal suppression - courses > 3 weeks
Hyperglycaemia
Psychosis
Insomnia
Indigestion
Mood swings
Diabetes
Cataracts
Glaucoma
Peptic ulceration
Susceptibility to infections
Osteoporosis
Muscle wasting
Skin thinning
Cushingoid appearance
```
152
Considerations for long term steroid use
PPI - reduce GORD
Bisphosphonates - bone protection
Steroid card
Should not be withdrawn abruptly
