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Pradeepa's notes > Respiratory System > Flashcards

Respiratory System Flashcards

1
Q

moderate acute asthma characteristics

A

-peak flow >50%
-able to complete full sentences
-sp02 ≥ 92%
-respiratory rate ≤ 30 (5+yr) ≤ 40 (1-5yr)

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2
Q

severe acute asthma characteristics

A

-peak flow 33-50%
-unable to complete full sentences
-respiratory rate ≥25 (adult) >30 (5+yr) >40 (1-5yr)
-heart rate >125bpm (5+)
>140bpm (1-5yr)

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3
Q

life-threatening acute asthma characteristics

A

-peak flow <33%
-sp02 <92%
-silent chest
-altered consciousness
-hypotension
-exhaustion

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4
Q

moderate acute tx adults

A

-home/primary care tx if inadequate response then hosp
-tx = high dose of salbutamol (SABA) via PMI + spacer

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5
Q

severe/life-threatening acute tx adults

A
  • hosp immediately
    -tx: high dose of salbutamol (SABA) via oxygen driven nebuliser +/ nebulised ipratropium
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6
Q

near fatal/ life threatening with poor response to initial tx acute tx adults

A
  • all pt = oral predn if x IV hydrocortisone or IM methylpredn
    -hypoxemic pt = supplementary oxygen (maintain sp02 94-98%)
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7
Q

acute asthma management children 2+

A

-severe/life-threatening = hosp immediately (o2 if life-threatening/sp02 <94%)
-1st line = salbutamol (SABA)
-mild-moderate = PMI + spacer if x controlled within 10PU - medical attention
-severe/L-T = via o2 driven nebuliser
-all cases 3DY predn

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8
Q

acute asthma management children 2yr+ 2nd line

A

-poor initial response to b2 agonist = + nebulised ipratropium
-poor response to 1st line = IV mg sulfate

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9
Q

acute asthma management children under 2

A

-refer to hosp
-moderate + severe = immediate o2 + trial SABA
-if needed + nebulised ipratropium bromide

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10
Q

chronic asthma tx

A

-lifestyle changes
-weight loss (obesity)
-smoking cessation
-breathing exercise programs

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11
Q

chronic asthma adult tx step 1

A

intermittent reliever SABA

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12
Q

chronic asthma adult tx step 2

A

-SABA + low dose regular preventer (ICS)
-start ICS if asthma uncontrolled by SABA alone (using SABA 3x WK, symptoms 3xWK, night time awakening at least OW, using >1 inhaler MT)

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13
Q

chronic asthma adult tx step 3

A

SABA + ICS +
-LTRA (nice)
-LABA (BTS/SIGN) fixed doses/ MART (maintenance and reliever therapy)

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14
Q

chronic asthma adult tx step 4

A

LABA if not already added
-can be given with or w/o LTRA
-can convert fixed doses of LABA + moderate strength ICS into MART

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15
Q

chronic asthma adult tx step 5

A

-increase strength to high strength ICS or initiate (specialist)
-theophylline
-tiotropium
-oral corticosteroids
-monoclonal antibodies

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16
Q

chronic asthma children 5yr+ tx step 1

A

intermittent reliever SABA

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17
Q

chronic asthma children 5yr+ tx step 2

A

regular preventer ICS very low strength
-start ICS if asthma x controlled by SABA alone

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18
Q

chronic asthma children 5yr+ tx step 3

A

SABA + ICS +
-LTRA (NICE)
LABA (BTS/SIGN) = 12+

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19
Q

chronic asthma children 5yr+ tx step 4

A

-replace LTRA with LABA if not on it
-can be given as MART if no change

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20
Q

chronic asthma children 5yr+ tx step 5

A

high strength ICS or initiate:
-oral corticosteroids
-theophylline
-monoclonal antibodies
-tiotropium (12+)

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21
Q

chronic asthma children <5yr tx step 1

A

-intermittent reliever SABA
-if using >1 inhaler refer asap

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22
Q

chronic asthma children <5yr tx step 2

A

-SABA + ICS low dose
-start if uncontrolled alone (symp 3xWK, night awakening 1xWK)
-use paed low dose for 8wk as trial
-if ICS x tolerated -> LTRA (montekulast)

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23
Q

chronic asthma children <5yr tx step 3

A

SABA + ICS + LTRA
-if x controlled - refer to specialist

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24
Q

chronic asthma dropping down

A

-asthma controlled = 3MT at least
-regular reviewed when lowering tx
-maintenance at lowest dose of ICS
-> reductions considered every 3MT - 25-50% each time

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25
Q

chronic asthma complete control

A

-no day time symp
-no night wakening due to asthma
-no asthma attacks
-no need for rescue medications
-no limitations on activity (incl exercise)
-normal lung function (Fev, and/or PEF >80% predicted/best)
-minimal s/e from tx

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26
Q

COPD

A

-progessive + x fully reversible
-persistent resp symptoms
-airflow limitation due to combination of obstructive bronchocitis + emphysema

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27
Q

COPD symp

A

-dsypnoea
-wheeze
-chronic cough
-regular sputum production

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28
Q

COPD risk factors

A

-major = SMOKING
-other; pollution, occupational exposures, genetic factors

29
Q

COPD step 1

A

SABA/SAMA

30
Q

COPD non asthmatic step 2

A

LAMA + LABA stop SAMA

31
Q

COPD non asthmatic step 3

A

-if pt = severe exacerbation or 2x moderate in 1yr
-LAMA + LABA + ICS
-if no changes AFTER 2MT then revert back to LAMA + LABA

32
Q

COPD asthmatic step 2

A

-LABA + ICS
-stop SAMA
-continue SABA

33
Q

COPD asthmatic step 3

A

-LAMA + LABA + ICS
-offer pneumococcal + influenza vaccine
-continue SABA
-theophylline, O2 therapy, mucolytic

34
Q

COPD exacerbation

A

-pt = exacerbation in last yr = rescue pack
-oral corticosteroids + antibiotic
->amoxicillin,
->doxycycline
->clarithromycin avoid if taking prophylactic azithromycin
-non-drug tx
-> positive expiratory pressure helps sputum clearance

35
Q

COPD exacerbation tx

A

-SABA/SAMA (withhold LAMA if SAMA given)
-hospitalised= short course prednisolone along with other therapies
-community = short course predn if sign breathlessness
-aminophylline added if inadequate response - nebulised bronchodilation
-oxygen if needed to keep o2 saturation of arterial blood levels in range

36
Q

SAMA / LAMA

A

SAMA = ipratropium
LAMA = tiotropium, aclidium, glycopyrronium

37
Q

SAMA / LAMA s/e

A

-antimuscarinic complications
-> constipation, dry mouth, high ocular pressure (report halos/blurred vision)

38
Q

SAMA / LAMA interactions

A

other antimuscarinic drugs

39
Q

ICS examples

A

-beclomethasone (BD)
-budesonide (BD)
-ciclesonide (OD)
-fluticasone (BD)
-mometasone (BD)

40
Q

ICS

A
  • beclomethasone brand QVAR + Kelhale = extra fine particles - 2x stronger than other inhalers
    -steroid cards if long-term high dose
    -monitoring children for height + weight annually in prolonged tx
    -taste + voice alterations
    -sore mouth = candidasis (decrease spacer + wash mouth)
    -paradoxical bronchospams - mild prevented by inhalation of SABA beforehand and change from aerosol to dry powder inhalation
41
Q

theophylline

A

-therapeutic range = 10-20mg/l
-check drug plasma lvls 4-6HR after each dose, 5DY after tx and 3DY after dose change
-brands = x same bioavailability

42
Q

theophylline s/e

A
  • vomiting
    -palpitations
    -arrythmias
43
Q

theophylline interactions

A

-smoking - inc theophylline clearance dec absorption (if pt stops smoking dose changes needed)
-fever = reduces clearance
-CYP enzyme inducers dec conc inhibitors inc conc
-hypokal; corticosteroids, SABA/LAMA, diuretics

44
Q

LTRA

A

-leukotriene receptor antagonists
-motelukast

45
Q

LTRA s/e

A

-MHRA warns neuropsychiatric reaction risk so report/refer speech/behaviour change
-churg-straws syndrome; eosinophilia, vakulitic rash, worsening pulmonary symptoms, cardiac complications or peripheral neuropathy

46
Q

LTRA interactions

A

CYP450 enzyme substrate

47
Q

croup mild tx

A

single dose of dexamethasone oral

48
Q

croup moderate-severe tx

A

-hosp = single dose of dexa/predn while waiting if x oral then IM dexa or nebulised budesonide
-severe = x controlled by steroids then nebulised adrenaline or epinephrine

49
Q

antihistamines types

A

oral
topical
nasal
eye drops

50
Q

antihistamines first gen

A

-more sedating
-alimemazine, promethazine more sedating than chlorphenamine, cyclizine

51
Q

antihistamines 2nd gen

A

-less sedating
-acrivastine, cetirizine, desloratadine, loratadine, fexofenadine
-n+v = cinnarizine, cyclizine, promethazine
-migraines = buclizine
-occasional insomnia = 1st gen

52
Q

allergen immunotherapy

A
  • immunotherapy using allergen vaccines reduces asthma symp + allergic rhino conjunctivitis
    -> can contain house dust mite, animal dander or pollen extract
  • vaccines containing bee/wasp venom - less risk of severe anaphylaxis
    -omalizumab = monoclonal antibody that binds to immunoglobin E (IgE)
    -additional therapy in proven IgE mediated sensitivity when severe persistent allergic asthma x controlled with ICS + LABA
    -S/E churg-straws syndrome + hypersenstiviity reactions
53
Q

anaphylaxis

A

-severe life-threatening hypersensitivity reaction rapidly developing airway circulation problems usually caused by allergen (foods, drugs, venom, latex)

54
Q

anaphylaxis immediate tx

A

-auto-injector immediately - IM adrenaline/epinephrine
-call 999 + state anaphylaxis - CPR if needed
-lie down + raise legs
-remove trigger
-repeat after 5 min interval if no improvement

-high flow 02 given asap if available
-IV fluids if hypotension/shock
-following stabilisation of pt = non-sedating oral antihistamine e.g. cetirizine or IM/IV chlorphenamine
-inhaled bronchodilator therapy = salbutamol and/or ipratropium bromide if persistent resp problems

55
Q

anaphylaxis MHRA guidelines

A

-always 2x injections carried and prescribed

56
Q

Adrenaline doses

A

-child 6MT - 100-150mcg
-6MT - 5yr = 150mcg
-6-11yr = 300mcg
-12+ = 500mcg

57
Q

cystic fibrosis

A

genetic disorder affecting lungs, pancreas, liver, intestine + reproductive organs - viscous sputum, chest infections and malabsorption

58
Q

cystic fibrosis tx

A

-prevent lung infections + maintain lung function
-mucolytic: dornase alfa - aids clearance of mucus/sputum from lungs
-long-term antibacterial considered to supress chronic staph.aureus
-nutrition + exocrine pancreatic insufficiency; pancreatin
-monitor pt - liver disease, diabetes, bone density

59
Q

how to use PDMI

A

-Shake the inhaler well.
-Sit or stand up straight and slightly tilt your chin up as it helps the medicine reach your lungs.
-Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in.
-Put your lips around the mouthpiece of the inhaler to make a tight seal.
-Start to breathe in slowly and steadily and, at the same time, press the canister on the inhaler once. Continue to breathe in slowly until your lungs feel full.
-Take the inhaler out of your mouth and with your lips closed hold your breath for up to ten seconds or for as long as you comfortably can.
-Then breathe out gently away from your inhaler.
-If you’ve been prescribed a second puff wait 30 seconds to a minute and shake the inhaler again, then repeat the steps.
-When you have finished replace the cap on the inhaler.

60
Q

how to use PDMI with spacer (single breath and hold technique)

A

–Breathe out gently and slowly away from the inhaler and spacer until your lungs feel empty and you feel ready to breathe in.
-Put your lips around the mouthpiece of the spacer to make a tight seal.
-Press the canister on the inhaler once and breathe in slowly and steadily until your lungs feel full.
-Take the mouthpiece of the spacer out of your mouth and with your lips closed, hold your breath for up to ten seconds or for as long as you comfortably can.

-Shake it well. If your spacer has a valve, make sure the valve is facing upwards. Put your inhaler into the hole at the back of the spacer.
-If your spacer has a cap, take it off. Sit or stand up straight and slightly tilt your chin up as this helps the medicine reach your lungs.
-The next steps all happen smoothly in one action.
-Breathe out gently and slowly away from the inhaler and spacer until your lungs feel empty and you feel ready to breathe in.
-Put your lips around the mouthpiece of the spacer to make a tight seal.
-Press the canister on the inhaler once and breathe in slowly and steadily until your lungs feel full.
-Take the mouthpiece of the spacer out of your mouth and with your lips closed, hold your breath for up to ten seconds or for as long as you comfortably can.
-Then breathe out gently away from the spacer.
-Some small volume spacers make a whistling sound if you’re breathing in too fast. If you’re using a large volume spacer like this one, you can use the same breathing technique.
-Finally, if you’ve been prescribed a second puff, with the spacer away from your mouth, wait 30 seconds to a minute and shake the inhaler again, then repeat the steps.
-When you’ve finished, take the inhaler out of the spacer and replace the caps on both the inhaler and the spacer.

61
Q

how to use PDMI with spacer (tidal breathing/multiple breath)

A

-This is usually recommended if you can’t hold your breath for five seconds after using your inhaler or if you are having an asthma attack.
-For most adults and older children, your spacer can be used with a mouthpiece, but a spacer with a mask may be given to you if you cannot put your lips around the mouthpiece to form a tight seal.
- Hold your inhaler upright and take the cap off. Check there’s nothing inside the mouthpiece. Shake it well.
-If your spacer has a valve, make sure the valve is facing upwards. Put your inhaler into the hole at the back of the spacer. If the mouthpiece of your spacer has a cap, take it off.
-Sit or stand up straight and slightly tilt your chin up as it helps the medicine reach your lungs.
-The next steps all happen smoothly in one action.
-Put your lips around the mouthpiece of the spacer to make a tight seal.
-Press the canister on the inhaler once to release the medicine and breathe in and out slowly and steadily into the spacer five times.
-Remove the inhaler and spacer from your mouth.
-If you’ve been prescribed a second puff, keep the spacer away from your mouth, wait a minute and shake the inhaler again. Then repeat the steps.
-Some small volume spacers make a whistling sound if you are breathing in too fast. If you are using a large volume spacer like this one, you can use the same breathing technique.
-With tidal breathing your spacer should make a clicking sound as the valve opens and closes.
-When you’ve finished, take the inhaler out of the spacer and replace the caps on both the inhaler and the spacer.

62
Q

How to use accuhaler?

A

Breathe out gently and slowly away from the inhaler, until your lungs feel empty and you feel ready to breathe in.
-Put your lips around the mouthpiece to make a tight seal.
-Breathe in quickly and deeply until your lungs feel full.
-Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can.
-Then breathe out gently away from your inhaler.

This is a dry powdered device or a DPI. Getting your inhaler technique right is very important because it helps you manage your symptoms better.
-To use your inhaler, first slide open the cover. Check there’s nothing inside the mouthpiece and check the dose counter to make sure there are enough puffs left.
-Hold the inhaler horizontally, but don’t tip it upside down as the powder may fall out.
-Load the device by pushing back the lever with your thumb until it clicks.
-Sit or stand up straight and slightly tilt your chin up as this helps the medicine reach your lungs.
-The next steps all happen in one smooth action. Breathe out gently and slowly away from the inhaler, until your lungs feel empty and you feel ready to breathe in.
-Put your lips around the mouthpiece to make a tight seal.
-Breathe in quickly and deeply until your lungs feel full.
-Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can.
-Then breathe out gently away from your inhaler.
-If you’ve been prescribed a second puff, slide the cover closed to reset the inhaler and repeat the steps

63
Q

Autohaler

A

Breathe in slowly and steadily continuing to breathe in when you hear a click and feel a puff of medicine in your mouth. Take the inhaler out of your mouth and hold your breath for up to 10 seconds or for as long as you comfortably can. Then breathe out gently away from your inhaler.

Lower the red lever. Your inhaler is now ready to use. First, take off the cover by pulling down the lip at the back. Check that there is nothing inside the inhaler mouthpiece. Hold the inhaler upright, making sure you’re not covering the air vents at the bottom. Shake the inhaler well. Flip the red lever on the top up until it clicks into place. Sit or stand up straight and slightly tilt your chin up as it helps the medicine reach your lungs. The next steps all happen smoothly in one action. Breathe out gently and slowly, away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece of the inhaler to make a tight seal. Breathe in slowly and steadily continuing to breathe in when you hear a click and feel a puff of medicine in your mouth. Take the inhaler out of your mouth and hold your breath for up to 10 seconds or for as long as you comfortably can. Then breathe out gently away from your inhaler.

64
Q

easyhaler

A

Don’t tip the inhaler upside down as the powder may fall out. Push down on the coloured button until you hear it click. Then release it. Your dose is now ready. Sit or stand up straight and slightly tilt your chin up as it helps the medicine reach your lungs. The next steps all happen smoothly in one action. Breathe out gently and slowly away from the inhaler, until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece to make a tight seal, then breathe in quickly and deeply until your lungs feel full. Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can. Breathe out gently away from your inhaler.

65
Q

breezhaler

A

Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece to make a tight seal. Then breathe in quickly and deeply until your lungs feel full. You should be able to hear a vibrating noise. Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can.

Open the inhaler by pushing the mouthpiece back. Next, take a capsule from the blister pack. Only use a capsule if it’s been sealed inside the foil blister pack. Put the capsule inside the inhaler. It’s important to put the capsule into the inner chamber and not into the mouthpiece. Close the inhaler until you hear a click. Press and release the two buttons at the side of the inhaler to make a hole in the capsule. Your dose is now ready. Hold the inhaler horizontally but don’t tip it upside down as the powder may fall out. Sit or stand up straight and slightly tilt your chin up as it helps the medicine to reach your lungs. The next steps all happen smoothly in one action. Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece to make a tight seal. Then breathe in quickly and deeply until your lungs feel full. You should be able to hear a vibrating noise. Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can. Then breathe out gently away from the inhaler. If you can’t hear the vibrating noise when you breathe in, the capsule may be stuck in the inner capsule chamber. Open the inhaler by pushing the mouthpiece back and loosen the capsule by gently tapping the base of the inhaler. Close the mouthpiece and follow the steps again, starting by breathing out slowly and gently. When you’ve finished, open the inhaler and check that the capsule is empty. If it is, tip it out into the bin, close the inhaler and replace the cap.

66
Q

handihaler

A

Breathe out gently and slowly, away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece to make a tight seal, then breathe in quickly and deeply until your lungs feel full. You should be able to hear a vibrating noise. Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can. Then breathe out gently away from the inhaler. To make sure you empty the capsule completely, repeat these steps again

Check there’s nothing inside the mouthpiece. Next, open the mouthpiece. Take a capsule from the blister pack. Only use a capsule if it has been sealed inside the foil blister pack. Put the capsule inside the inhaler. It is important to put the capsule into the inner chamber and not into the mouthpiece. Close the mouthpiece until you hear a click. Press and release the green button fully to make a hole in the capsule. Your dose is now ready. Hold the inhaler horizontally, but don’t tip it upside down as the powder may fall out. Sit or stand up straight and slightly tilt your chin up as it helps the medicine reach your lungs. The next steps all happen smoothly in one action. Breathe out gently and slowly, away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece to make a tight seal, then breathe in quickly and deeply until your lungs feel full. You should be able to hear a vibrating noise. Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can. Then breathe out gently away from the inhaler. To make sure you empty the capsule completely, repeat these steps again. If you can’t hear the vibrating noise when you breathe in, the capsule may be stuck in the inner capsule chamber. Open the inhaler by pushing the mouthpiece back and loosen the capsule by gently tapping the base of the inhaler. Close the mouthpiece and follow the steps again, starting by breathing out slowly and gently. When you’ve finished, open the mouthpiece, tip out the empty capsule into the bin and close the mouthpiece

67
Q

Respimat

A

Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece of the inhaler to make a tight seal without blocking the two holes on either side. Start to breathe in slowly and steadily, and at the same time, press the big grey button on the inhaler once. Continue to breathe in slowly until your lungs feel full. Take the inhaler out of your mouth and hold your breath for up to ten seconds, or for as long as you comfortably can.

Respimat inhaler, you will receive a pack containing an empty inhaler and a cartridge that you will need to insert. Repeat prescriptions will usually just be for a refill cartridge. However, you will need a new inhaler every six months. Before using your Respimat inhaler, you will need to prepare it. To insert a cartridge, keep the cap closed and press the safety catch on the side to remove the clear base. Insert a new cartridge into the inhaler and click it into place by pressing the inhaler down on a firm surface. Remember to mark on the check box on your inhaler to indicate that you have used a new cartridge, and then put the clear base back into place. Now you need to prime your inhaler. Hold your inhaler upright with the cap closed. You should only turn the base when the cap is closed, otherwise the inhaler may spray a dose as you turn the base. Turn the clear base in the direction of the arrows until it clicks. Open the cap fully. Point the inhaler towards the floor away from you and press the big grey button. Close the cap. If you do not see a white cloud, repeat the priming sequence until you see a cloud. Once you can see a cloud, repeat the priming sequence three more times. Your inhaler is now ready for use. If you have not used your inhaler for one to three weeks, you will need to repeat the priming sequence once. If you have not used your inhaler for more than three weeks, you will need to repeat the priming sequence as if you are preparing a new inhaler. Your inhaler is now ready for use. First, check the dose indicator to make sure the cartridge is not empty. Hold the inhaler upright, with the cap closed. Turn the base in the direction of the arrows until it clicks. Push up the catch on the side of the inhaler and open the cap. Hold the inhaler horizontally. Check that there is nothing inside the inhaler mouthpiece. Sit or stand up straight and slightly tilt your chin up, so that you’re pointing the inhaler towards the back of your throat. The next steps all happen smoothly in one action. Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece of the inhaler to make a tight seal without blocking the two holes on either side. Start to breathe in slowly and steadily, and at the same time, press the big grey button on the inhaler once. Continue to breathe in slowly until your lungs feel full. Take the inhaler out of your mouth and hold your breath for up to ten seconds, or for as long as you comfortably can. Then breathe out gently away from your inhaler. Wait for 30 seconds and repeat for a second puff, remembering to close the cap before you turn the base. When you have finished, close the cap on the inhaler. When the cartridge in the inhaler is empty, the dose counter will turn red and show a down arrow. This indicates that you need to replace the cartridge. As you turn the clear base, it will loosen and your inhaler will be in a locked position. Pull out the empty cartridge from the inhaler and then insert a new cartridge as before. When you have used an inhaler with six cartridges, you should get a new Respimat inhaler device.

68
Q

easi-breathe

A

First, hold the inhaler upright and shake the inhaler well. Then open the cap. Check there’s nothing inside the mouthpiece. Make sure you’re not covering the air holes at the top. Sit or stand up straight and slightly tilt your chin up as it helps the medicine reach your lungs. The next steps all happen smoothly in one action. Breathe out gently and slowly away from the inhaler until your lungs feel empty and you feel ready to breathe in. Put your lips around the mouthpiece of the inhaler to make a tight seal. Breathe in slowly and steadily. Continue to breathe in when you feel the inhaler puff in your mouth until you have taken a full deep breath in. Take the inhaler out of your mouth and hold your breath for up to ten seconds or for as long as you comfortably can, then breathe out gently away from the inhaler. If you’ve been prescribed a second puff, close the cap, wait one minute and shake the inhaler again.

Pradeepa's notes (12 decks)

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