Fatima Omrani and Hafsah Choudry – St.

Georges Hospital Pre-registration Year 2018-19

RESPIRATORY SYSTEM

1. ASTHMA
• Complete control of asthma is defined as no daytime symptoms, no night-time awakening due to asthma, no asthma attacks, no need for rescue
medication, no limitations on activity including exercise, and normal lung function.
• FEV/PEF >80%
• To avoid unwanted side effects and unnecessary costs, treatment is gradually stepped down every three months (25–50% each time) once control is
achieved for 3 months. Patients should be maintained at the lowest possible dose of inhaled corticosteroid.
• Step up: using SABA three times a week, more than 1 inhaler a month, symptoms three times a week, waking at due to symptoms at night once per
week (+ BTS = asthma attack in the past 2 years)
• Children: Spacer device in under 5s

ACUTE ASTHMA ATTACK (hospitalised)

Treat acute moderate at home and acute severe in hospital

I. High flow oxygen (40-60%) to maintain a SpO2 level between 94–98%

II. High dose inhaled (or nebulised in severe cases) SABA
+ oral prednisolone OD (40mg OD children =3 days and adults = 5 days)
III. No improvement: + nebulized ipratropium bromide
or IV dose of magnesium sulfate or IV aminophylline

Oxygen
94-98% aim for all
88-92% for patients at risk of hypercapnic respiratory failure – COPD, CF, opioid or benzodiazepine
overdose

Peak Flow Meter

1. Move marker to 0
2. Take a deep breath
3. Put lips around mouthpiece and blow out as hard and fast as you can
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

MANAGEMENT OF ASTHMA – Treatment Pathways

Adults and >17 (NICE Guidelines) Children 5 - 16 (NICE Guidelines) Children under 5 years (NICE Guidelines)
1. SABA 1. SABA 1. SABA
2. Add Low dose ICS 2. Add Pediatric low dose ICS 2. Add pediatric ICS for 8 weeks
3. Add LTRA (r/v at 4-8 weeks) 3. Add LTRA (unlicensed under 12) a. If recur within 4 weeks of
4. Add LABA (+/- LTRA) 4. Remove LTRA and add LABA stopping – add ICS again
5. Use MART (fast acting LABA +/- LTRA) 5. Use as MART
b. If recur after 4 weeks of stopping
a. Start at low, medium, high dose ICS a. Start at pediatric low, moderate, high ICS
– trial 8 weeks again
6. Then add a trial LAMA or MR Theophylline 6. Then add a trial of LAMA or MR Theophylline
3. Add LTRA
Adults and >12 (BTS Guidelines) Children 5 - 16 (BTS Guidelines)
1. SABA 1. SABA Children under 5 years (BTS/SIGN
2. Add Low dose ICS 2. Very low dose ICS (5-12) or Low dose ICS (12-16) Guidelines)
3. Add LABA 3. Add LABA (5-16) or LTRA (5-12) 1. SABA
a. If LABA helps but not enough – a. If LABA helps but not enough – increase ICS to 2. Add pediatric low dose ICS, or LTRA if can’t
increase ICS to medium low (5-12) medium (12-16) take ICS
b. If LABA doesn’t help – STOP and b. If LABA doesn’t help – STOP and increase ICS to 3. a. 2–5 years, add LTRA or ICS
increase ICS to medium low (5-12) medium (12-16) b. under 2 years, proceed to referral
4. Reduce ICS to low (+LABA) and add 4. Reduce ICS to low (+LABA) and add LTRA/LAMA/MR
LTRA/LAMA/MR Theophylline Theophylline
5. Increase ICS/LAMA/MR Theophylline/LRTA 5. Increase ICS/LAMA/MR Theophylline/LRTA
6. Oral prednisolone 6. Oral prednisolone

*<15 – always use a spacer

*Vilanterol and Fluticasone (Relvar Ellipta) is the only one which is OD not BD

MART Therapy: Maintenance and Reliever Therapy is a combination inhaler used as both preventer and reliever
Use MART inhaler every day, even when feeling well.
Over 18s only except SMART (Symbicort MART) which can be used in over 12’s
• Symbicort MART Regime (also known as SMART) = budesonide and formoterol
• Fostair MART Regime = beclomethasone and formoterol
• DuoResp Spiromax MART Regime = budesonide and formoterol
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

2. COPD
• Smoking cessation reduces mortality and increases prognosis + pneumococcal and influenza vaccine
• Long-term oxygen therapy (15 hours a day) is needed in severe COPD and hypoxaemia.
• Exacerbations are treated with nebulised bronchodilators (salbutamol or ipratropium); oxygen if needed, antibiotics if infection is suspected, and 30mg
OD for 7 to 14-day course of corticosteroid is breathlessness interferes with daily activity.
• If its infection: Side effects are confusion
Causative organisms of COPD exacerbations: H. Influenza, Moraxella Catarrhalis, S. Pneumoniae. (CF: S.aureus, pseudomonas)
First line: Tetracyclines (Doxy), Amoxicillin, Macrolides GOLD
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

Bronchodilator Drug Comments Side-effects Warnings/monitoring

Short acting Beta2 agonist • Salbutamol • Short-acting β2-agonists are used to • Hypokalaemia (it • Caution when using with
• Terbutaline relieve breathlessness. therefore can be used theophylline, steroids &
Long acting Beta2 agonist* • Formoterol – • Long-acting β2-agonists are used as ‘step as treatment of diuretics as increases risk
longer acting used 3’ treatment for chronic asthma but must hyperkalaemia + of hypokalaemia.
in MART therapy always be given in combination with insulin, glucose and • B-blockers can reduce
• Salmeterol – inhaled corticosteroids. Also used second calcium gluconate) effectiveness
shorter acting line in COPD. • tachycardia • Prolong QT
• Can be used IM • Tremor.
Antimuscarinics • Ipratropium • Short term relief in asthma and COPD • Arrhythmias, dry • Care needed to protect
(Atrovent) (Beta2 agonist are quicker acting) – ipra mouth, cough, patient's eyes from
MHRA warning about bromide- SAMA effects last 3-6 hours dizziness, nose bleeds, nebulised drug or from
choking • Glycopyrronium • Bind to the muscarinic Veptor, where headache, nausea drug powder as = acute
Caution if eGFR <50 bromide they act as a competitive inhibitor of • Hypokalaemia angle-closure glaucoma
• Umcledinium acetylcholine = reduce smooth muscle • Antimuscarinic SE (particularly when given
• Tiotropium tone, including in the respiratory tract; with nebulised
(Spiriva) and reduce secretions in respiratory tract salbutamol)
• Ipratropium – can be used in asthma only
when asthma exacerbations
• Tiotropium – only used in asthma when
last line
Xanthine • Aminophylline • Addictive effect if symptoms persist See below (high risk drug)
• Theophylline

CHM ADVICE: formoterol and salmeterol for chronic asthma, should:

• Be added if control with regular ICS has failed
• Not be initiated in patients with rapidly deteriorating asthma
• Be introduced at a low dose and the effect properly monitored before considering dose increase
• Be discontinued in the absence of benefit
• Not be used for the relief of exercise-induced asthma symptoms unless regular inhaled corticosteroids are also used
• Be reviewed as clinically appropriate: step down therapy should be considered when good long-term asthma control has been achieved
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

Class Drug Comments Side-effects Warnings/monitoring

Inhaled • Beclomethasone (brands • Anti-inflammatory 1. Oral thrush (rinse mouth after • Increases the risk of
corticosteroid* not interchangeable - • Can be given as combo product use + can treat using oral pneumonia in COPD pts
Qvar more potent than with long acting Beta2 agonist antigungal suspension or gell • Monitor height and weight
Clenil Modulate) (Seretide, Symbicort, Fostair-more 2. Paradoxical bronchospasm – of children receiving
• Budesonide potent as has extra fine particles treat by inhaling SABA before ICS prolonged treatment
• Fluticasone so lower dose) dose or converting from aerosol annually. Refer to peads if
• Takes 3-7 days for symptoms to to dry powder growth slowed
start alleviating 3. Hoarse voice • Need steroid card with high
4. Glaucoma doses
5. Pneumonia – increased in COPD

High doses SE:

• Growth suppression
• Reduced bone mineral density
• Adrenal suppression
Leukotriene • Montelukast • Block effects of leukotrienes in 1. Diarrhoea • Churg-Strauss syndrome
receptor <5 = 4mg OD airways 2. GI discomfort with Zafirlukast with steroid
antagonist >5 = 5mg OD • Monotherapy or w/ ICS 3. URTI withdrawal (rash, worse resp
(inflammatory Adult = 10mg OD • Benefit exercise induced asthma symptoms, cardiac
mediators) • Zafirlukast • Less beneficial in those with complications or
severe asthma who are receiving neuropathy)
Can be mixed with cold high doses of other drugs • Hepatic disorder (nausea,
soft food • Limited information in pregnancy vomiting, malaise, jaundice)
Mast-cell • Sodium cromoglicate • Can help asthma with a allergic Paradoxical bronchospasm –
stabilisers • Nedocromil sodium basis and exercise induced asthma treat by inhaling SABA and stop
the nedocromil sodium
Oxygen • The target SpO2 should • Long-term oxygen therapy can be
be 94–98% in most and given to severe COPD and asthma
88–92% in those with patients
chronic T2 respiratory
failure (COPD, CF)
MHRA ALERT: risk of central serous chorioretinopathy with ICS or PO corticosteroids so pts should report any blurred vison or other visual disturbances.
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

THEOPHYLLINE (HIGH RISK)

Dose Warning signs (report to Dr ASAP) Monitoring Interactions Other

Therapeutic Range: • Toxicity 1. Serum potassium 1. Caution when using with Beta2 • Maintain same brand:
10 to 20mg/L Diarrhea, Vomiting, Agitation, 2. Plasma conc agonist, steroids & diuretics as The rate of absorption
(although a plasma restlessness, dilated pupils, (measured 5 days increases risk of hypokalaemia. from modified-release
theophylline tachycardia, hyperglycemia, after starting) and 3 2. Increased plasma concentration preparations can vary
concentration of 5 convulsions, hypokalaemia days after any dose with diltiazem, oestrogens, between brands.
to 15mg/L may still • Overdose treatment: activated adjustment fluvoxamine, verapamil and • Pregnancy & BF:
be effective); charcoal and BB to reverse 3. Blood sample 4-6 inhibitors Risk of asthma
loading doses may tachycardia, hypokalemia and hours after IV dose 3. The plasma-theophylline exacerbations
be required hyperglycemia concentration is increased in heart outweighs risk of
• Poor asthma control failure, hepatic impairment, viral treatment; continue
Brand Specific cough, wheeze, tight chest, infections, in the elderly taking as normal with
frequent courses of steroids or 4. Possible increased risk of monitoring
antibiotics convulsions when theophylline • Contents of capsule
given with quinolones can be sprinkle on
5. Reduced plasma concentrations soft food
with alcohol, and inducers
6. The plasma-theophylline
concentration is decreased in
smokers, dose adjustment may be
necessary; inform GP before
stopping or starting smoking
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

Dry powder – quickly and deeply

Aerosol – Slowly and deeply
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

Ellipta: In a foil container

Genuair: green to red
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

3. CROUP
• Barking cough, hoarse voice & difficulty breathing (age: 6 months to 6 years)
• Mild croup is largely self-limiting; but treatment with a single dose of a corticosteroid e.g. dexamethasone is usually offered.
• More severe croup (or mild croup that might cause complications) calls for hospital admission, dexamethasone or budesonide (by nebulisation) will
often reduce symptoms; the dose may need to be repeated after 12 hours if necessary. If still not controlled, nebulised adrenaline solution is given.

4. ALLERGIC CONDITIONS

Class Drug Comments Side-effects Warnings/monitoring

Sedating • Chlorphenamine* (P) • First-line treatment for Sedation • Avoid in sever liver disease
antihistamines > 1 years (solution) allergies, particularly hay fever =encephalopathy
(First generation) DA x EPSE • As an adjunctive treatment in • Children under 6 should not be
• Promethazine* (P) anaphylaxis, after given cough and cold remedies
Antimuscarinic > 2 years administration of adrenaline containing chlorphenamine
• Angioedema • Avoid in glaucoma, epilepsy, GI
obstruction and BPH
Non-sedating • Loratadine (P) Less adverse effects
antihistamines > 2 years than first-generation
(second • Cetirizine (GSL = 7
generation) capsules only. 30
tablets are POM)
> 2 years
• Fexofenadine

MHRA ALERT: Children under 6 years old should not be given cough and cold preparations containing chlorphenamine or promethazine

ANAPHYLAXIS: Restore BP + Adrenaline + oxygen + IV antihistamines + IV corticosteroids (40mg OD for 7 days)

Dose of intramuscular injection of adrenaline (epinephrine) for the emergency treatment of anaphylaxis by HCP
Age Dose Volume of adrenaline
Child 1 months- 5 years 150 micrograms 0.15ml in 1000 (1mg/1ml) adrenaline
Child 6-11 years 300 micrograms 0.3ml in 1000 (1mg/1ml) adrenaline
12 years + 500 micrograms 0.5ml in 1000 (1mg/1ml) adrenaline
These doses may be repeated several times if necessary, at 5-minute intervals according ot blood pressure, pulse and respiratory function
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

5. CYSTIC FIBROSIS
• Pulmonary disease with recurrent infections, production of copious viscous sputum and malabsorption (mainly but also effects pancreas, liver,
intestine and reproductive organs)
• Aim to prevent and manage lung infections, loosening or removing thick, sticky mucus from lungs, preventing or treating intestinal obstruction and
providing sufficient nutrition and hydration
• Infections causative agent: Staph. Aureus

Class Drug Comments Side-effects Warnings/monitoring

Mucolytics • Dornase alfa (1st line)
• Hypertonic sodium chloride
(2nd line)
• Mannitol (3rd line)
• Acetylcysteine
• Carbocisteine
• With dornase alfa, liver function should be • GI disruption • Avoid with history
monitored every 3 months during the first year • GI haemorrhage - of ulceration
of treatment, then annually thereafter bleeding • Takes 2-3 weeks to
• Liver dysfunction work
• Mannitol should be administered 5-15mins • Reduces viscosity of
after bronchodilator & before pyhsio as can mucous in gastric
cause bronchospasm membranes =
peptic ulcer

6.0 COMMON COLD

Cold
Sympathomimetic Pseudoephedrine (max 1 pack) Insomnia >6
Constrict dilated blood vessels and swollen Phenylephrine Tachycardia >12
nasal mucosa, easing congestion and helping to MAOi – HTN crisis
breathe. BB avoid
Avoid in HTN
Topical decongestant Xylometazoline nasal spray/drops 7 day (Otrivine) >12
Children’s nasal drops 5 days (Otrivine) >6
Oxylometazoline
Antihistamine Diphenhydramine Dry mouth Syrup >1
Sedation Tablet >12
Constipation
Maximum pack sizes: 720 mg (the equivalent of 12 tablets or capsules of 60 mg or 24 tablets or capsules of 30 mg), and sales are restricted to one pack per
person owing to concerns over illicit manufacture of methylamphetamine (crystal meth).
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

7.0 COUGH AND CONGESTION

• Acute cough = <3 weeks and chronic cough >8 weeks
• OTC cough and cold medicines can be considered for children aged 6–12 years, but treatment should be restricted to 5 days or less.
• REFER once the pharmacist has recommended an appropriate treatment, patients should see their doctor 2–3 weeks after the cough started if it has
not improved or sooner if it is getting worse.
CHM Advice:
< 6 years not given OTC cough and cold remedies containing…
• Brompheniramine, chlorphenamine, diphenhydramine, doxylamine, promethazine, triprolidine – Antihistamines
• Dextromethorphan, pholcodine – cough suppressants
• Guaifenesin – expectorants
• Phenylephrine, pseudoprime, ephedrine, oxymetazoline, xylometazoline – decongestants

< 6 years not given OTC cough and cold remedies containing…
• Maximum 5 days of OTC treatment
• Max 1 cough/cold product at a time

Cough
Guaifenesin – chesty Cough expectorant - Used for expulsion of bronchial Pregnancy – ok >6
secretions, but there is no evidence for effectiveness.
Diphenhydramine- chesty Antihistamine (Antimuscarinic Side Effects) Dry mouth >6
Sedation
Constipation
Pholcodine Avoid in 3rd trimester >6
Dextromethorphan Avoid in asthmatics >6
Codeine linctus Codeine may be effective, but it is constipating and can Sedation >18
cause dependence; dextromethorphan and pholcodine Constipation And tablets >12
have fewer side-effects.
Demulcents Contain soothing substances. >1
Provide a safe alternative for at-risk patient groups such
as the elderly, pregnant women, young children and
those taking multiple medication.
 Fatima Omrani and Hafsah Choudry – St. Georges Hospital Pre-registration Year 2018-19

8.0 SORE THROAT

Sore throat REFER: If >2 weeks, have skin rash, difficulty swallowing (dysphagia) or taking any of the medicines listed below as
may be an indication of agranulocytosis (A severe reduction in the number of white blood cells) which can manifest
Lidocaine >12
as a sore throat.
Benzocaine lozenge/spray >3/>6
Flurbiprofen >12
Captopril, carbimazole, cytotoxic, neuroleptics e.g. clozapine, penicillamine, sulfasalazine, Sulphur - antibiotics and
Benzydamine rinse >12
immuno suppressants
Benzydamine spray >6

9.0 RHINITITIS
• Inflammation of the nasal lining (viral infection, colds or allergic rhinitis)

• Symptoms: rhinorrhea (mucus filled nose), nasal congestion, sneezing and itching.

Rhinitis
Cetirizine (Zirtek) >6
Oral solution 1mg/ml >2
Loratadine (Clarityn) >2
Oral solution 5mg/5ml >2
Chlorphenamine (Piriton) Dry Mouth >6
Oral solution 2mg/5ml Sedation >1
Constipation
Avoid in glaucoma
Nasal Corticosteroids Avoid in glaucoma >18
Corticosteroid nasal sprays are, however, the most effective overall
treatment and should be the first line treatment in adults suffering from
moderate to severe cases of AR, or those who are still symptomatic despite
regular use of antihistamines.
Sodium Cromoglycate 2% eye drops (Optex) >6 GSL

10.0 WHOOPING COUGH

• If a pregnant woman is vaccinated – she will pass the immunity to the unborn child – do not return to school till 48hrs after starting abx