Chronic Respiratory

Asthma
- Goal
o Decrease intensity and frequency of symptoms
- Treatment
o Beta2 agonists
o Corticosteroids
o Leukotriene modifiers
o Cholinergic antagonists
o Theophylline
- Beta2 Agonists
o Short acting
§ For quick relief
§ Selective beta agonists
§ Salbutamol à Ventolin, butalin
• Evohaler, nebulizer solution, syrup and tablet
§ Terbutaline à Dilanyl syrup
o Long acting (LABA)
§ Salmeterol à Seretide (+ fluticasone propionate)
• Evohaler and diskus
§ Formoterol à Symbicort (+ budesonide formoterol)
§ Vilanterol à Relvar (+ fluticasone)
§ Indacaterol à Ultibro (+glycopyrronium)
§ Dosed twice daily
• Works for 12 hours
§ Never used as monotherapy
- Corticosteroid
o Drug of choice in long-term treatment
o Severe persistent asthma may require oral corticosteroid
 § Prednisolone à Predo
o Fluticasone à Flixotide
o Ciclesonide à Alvesco
o Pulmicort à Budesonide
- Alternative Medications
o Used with ICS therapy
o Leukotriene modifiers
o Cholinergic antagonists
o Theophylline
- Leukotriene Modifiers
o Montilukast à singulair
§ 4 mg (chewable tablets; granules), 5 mg (chewable tablets), 10 mg
(swallow tablet)
§ Selective antagonists of leukotriene
o Approved for prevention of asthma symptoms
o Effective in preventing exercise induced bronchospasm
- Cholinergic antagonists
o Ipratropium à Atrovent (SAMA)
§ Used with SABA for acute asthma
o Tiotropium à Spiriva (LAMA)
- Theophylline
o Bronchodilator and decreases symptoms
o Narrow therapeutic window – replaced with SABA
§ Overdose may cause seizures or fatal arrhythmias
o Euphyline retard
o Theoped
- Patient education
o Use SABA in asthma attacks
o Use spacers or chambers for geriatric and pediatrics
 COPD
- Symptoms
o Cough
o Excess mucus production
o Chest tightness
o Shortness of breaths
o Fatigue
o Difficulty sleeping
- Risks factors
o Smoking
- Treatment
o Bronchodilators
o Corticosteroids
o Other agents
- Other Agents
o Roflumilast à Daxas
o PDE-4 inhibitor used to reduce exacerbation in patients with severe chronic
bronchitis
o Use limited by common side effects including
§ N/V/D and headache
 Bronchitis
- Symptoms
o Cough
o High fever
o Headache, cold symptoms and aches/pain
o Symptoms typically peak after 2-3 days then gradually clear out
- When to refer
o Wheezing or worsening headaches
o Fast and short breaths
o Chest pain
o Coughing blood or dark/rusty sputum
o Cough persists for longer than 3-4 weeks
- Treatment
o Paracetamol and NSAIDs
o Decongestant
o Cough syrup
o Antibiotics

Pneumonia
- Symptoms
o Cough, purulent sputum which may contain blood
o High fever
- Treatment
o Analgesics
o Normal saline nebulizer
o Antibiotics
 Nebulizer
- Drugs used
o Bronchodilators
o Anticholinergics
o Corticosteroids
o Normal saline
- Benefits
o Can mix medications together to be inhaled
o Can use different concentrations of each medication
o Doesn’t require hand/breath coordination
§ Where you have to take deep breaths before inhaling the medication
from inhalers
- Treatment Areas
o Bronchi
§ To dilate bronchioles
o To reach the alveoli, you need particle sizes to be less than 1 micrometer but we
don’t have any devices that can make particles this size
- Nebulizer types
o Compressor
§ Disadvantages à loud noise
o Ultrasonic
o Vibrating mesh
- Brands
o Omron
o Citizen
o Philips
- Features
o Residual volume
§ The amount of medication is left after using the nebulizer
 § Omron C 30 à 0.7 mL residual volume
§ Omron U 22 à 0.1 mL residual volume
o Nebulization rate (delivery time; session time)
§ The length required for a complete treatment
§ Omron C 30 à 0.35 mL/min
§ Omron C 28 à 0.4 mL/min
§ Citizen CUN 60 à 0.2-0.7 mL/min (adjustable)
• High rate can cause discomfort
o Mass median aerodynamic diameter of particles (MMAD)
§ Particle sizes deliver; must be at least less than 5 micrometers
§ Omron U 22 à 4-5 mm
§ Omron C 30 à 2.9 mm
§ Omron C 28 à 3 mm
§ No difference between them all
o Power supply
§ Needs battery or outlet
§ Omron U 22 is the only battery operated device
o Portability
§ Omron U 22 easily portable due to weight, size and power supply
• Pocket nebulizer
o Orientation
§ All devices require patients to be sitting up
§ Omron U 22 à allows patients to lay down while using it
o Sound
§ Omron U 22 à vibrator mesh
• No sounds
§ Citizen CUN 60 à ultrasound
• No sounds
 o Attraction for children
§ Philips Sami the seal – nebulizer looking like sea seals
§ Appealing to children
§ Omron à duck
- Features Selection Criteria
o Technical
§ Nebulization rate
§ Particle size
§ Residual volume
o Practical
§ Sound
§ Orientation
§ Power supply
§ Portability