Prescribing in Respiratory Medicine

What is asthma?

• inflammation and narrowing of small airways

• usually intermittent and reversible

• causes cough, wheeze, chest tightness and SOB

• can affect in children or adults

What is COPD?

• chronic airflow obstruction

• causes air trapping, SOB, cough, wheeze, sputum production

• usually as result of smoking or environmental exposure

Compare asthma and COPD?

What type of white blood cell is primarily involved in asthma-related inflammation?

• eosinophils 

What triggers eosinophilic inflammation in asthma?

• allergens such as pet dander

What type of white blood cell is primarily involved in COPD-related inflammation?

• neutrophils 

What triggers neutrophilic inflammation in COPD?

• Inhalation of toxins, especially cigarette smoke.

What is a key feature of eosinophils in asthma?

• pro-inflammatory and associated with persistent inflammation

What is a key consequence of neutrophil activation in COPD?

• tissue destruction and airway inflammation

What is the most cost effective COPD intervention according to QALY?

• flu vaccination 

What are group A COPD patients and what is the inital treatment?

• few symptoms and low risk of exacerbations 

• bronchodilator

What defines group E patients in COPD and what is the treatment?

• ≥2 moderate exacerbations or ≥1 hospitalization.

What defines group B patients in COPD and what is the treatment?

• mMRC ≥ 2 or CAT ≥ 10. - low risk and more symptoms

  • mMRC - Modified medical research council dyspnea questionnaire

  • CAT - COPD assessment test

• LABA + LAMA.

What should be considered before adjusting asthma medication?

• Alternative diagnoses

• comorbidities

• inhaler technique

• smoking

• psychosocial and environmental factors.

What is the first-line treatment for newly diagnosed asthma in patients aged ≥12?

• low-dose ICS/formoterol combination inhaler as needed (AIR therapy).

When should moderate-dose MART be considered?

• If asthma remains uncontrolled on low-dose MART.

What should be checked if asthma is uncontrolled despite good adherence to moderate-dose MART?

• FeNO level and blood eosinophil count.

What add-on therapies are trialed if eosinophils or FeNO are raised?

LTRA or LAMA for 8–12 weeks.

What is the next step if asthma is uncontrolled on high-dose ICS?

• Refer to a specialist in asthma care.

What defines uncontrolled asthma?

• Exacerbations needing oral steroids, reliever use ≥3 days/week, or night waking ≥1/week.

What is poor asthma control?

• need to use reliver inhaler >3x per week

• night time symptoms 

• chest tightness

• cough 

• SOB 

• wheeze 

• exercise symptoms 

• reduced peak flow

  • moderate – 50-75% best/pred. PEF

  • severe – 33-50% best/pred. PEF

  • life-threatening - <33% best/pred.PEF

What is poor asthma control?

• wheeze 

• cough

• SOB

• sputum changes

• fatigue 

• grogginess or headache

What type of preventer inhaler is used in asthma?

• ICS, with LABA or LAMA added if needed

What are the preventer inhaler options in COPD?

• LABA or LAMA; LABA/LAMA; LABA/LAMA + ICS if indicated.

What is the reliever inhaler used in both asthma and COPD?

• SABA (short-acting beta agonist).

Which condition may use a MART regimen?

• asthma 

Should patients with asthma or COPD have a written clinical management plan?

• yes for both conditions

What physical activity intervention is recommended for COPD?

• pulmonary rehabilitation 

How is weight managed differently in COPD?

• reduce if high

• increase if low

What vaccination is recommended for both asthma and COPD?

• flu vaccination 

What is the prednisolone dose for asthma exacerbations?

• 40mg for 5 days 

What is the prednisolone dose for COPD exacerbations?

• 30mg for 5-7 days 

  • if first episode of exacerbation - 5 days 

  • if patient prone to exacerbation - 7 days 

When are antibiotics indicated in asthma or COPD exacerbations?

• if signs of infection 

What type of nebuliser is used in asthma exacerbations?

• Oxygen-driven nebuliser with salbutamol 2.5 mg and ipratropium 500 mcg

What type of nebuliser is used in COPD exacerbations?

• Air-driven nebuliser with salbutamol 2.5 mg and ipratropium 500 mcg.

What is the oxygen saturation target in asthma exacerbations?

• >94%

What is the oxygen saturation target in COPD exacerbations?

• >94%

• If CO2 retention = 88-92%

Is peak flow monitoring useful in asthma exacerbations?

• yes 

• monitor QDS and aim for PEF >75% of best before discharge.

How do SABAs work in the airway and give 2 examples?

• They bind to beta-2 receptors in airway muscles, causing relaxation.

• salbutamol and terbutaline

How long do LABAs typically last?

• around 12 hrs 

• Indacaterol lasts 24hrs 

Examples of LABAs?

• formoterol 

• salmeterol

• indacaterol 

How do SAMAs work and give example?

• work on the parasympathetic nervous system

• cholinergic nerves cause airways to tighten, by blocking these nerves they cause dilation 

• ipratropium bromide 

How long does it take for LAMAs to work and give examples?

• slow release over 12-24 hrs 

• Tiotropium, Aclidinium bromide (Eklira), Glycopyrronium bromide (Seebri), Umeclidinum (Ellipta).

  
  

What are inhaled corticosteroid inhalers and give examples?

• works by binding to common glucocorticoid receptor and suppress chronic inflammation

• Beclometasone, Budesonide, Fluticasone, Mometasone, Ciclesonide

Side effects of ICS?

• Oral thrush – ensure patients rinse their mouth after taking these

• Dry throat/mouth

• Hoarse voice

• Increased risk of pneumonia in COPD

What is the recommended eosinophil threshold for ICS use in COPD?

• only use ICS if eosinophils >0.3.

What is the minimum inspiratory flow needed for nebuliser aerosol to reach the lungs?

• 6-8L/min

What percentage of a nebulised drug dose is typically deposited in the lungs?

• about 10%

Why is drug loss high with nebulisers?

• Medication is retained in dead-space or lost in room air during expiration

Which is more effective: nebuliser or spacer with SABA?

• Spacer with SABA is more effective than a nebuliser

What is the usual dose of salbutamol used in nebulisers?

• 2.5mg 

Which inhaled antibiotic is sometimes used via nebuliser?

• colistimethate sodium (Colomycin)

When can nebulised medication be considered appropriate?

• If the patient has distressing breathlessness despite maximal inhaler therapy.

What are the benefits of nebulised therapy in select COPD patients?

• Reduces symptoms, improves ADLs, increases exercise capacity, and improves lung function.

What is the primary pathological feature of community acquired pneumonia?

• Infection causing consolidation of the lung parenchyma.

What types of pathogens commonly cause CAP?

• bacteria and viruses 

Name two typical bacterial causes of CAP.

• streptococcus pneumonia and haemophilus influenzae

Name one atypical bacterial cause of CAP?

• mycoplasma

Name four viral causes of CAP?

• respiratory syncytial virus 

• adenovirus 

• influenza

• COVID

List common symptoms of CAP?

• pleuritic chest pain

• cough 

• fever

• SOB

• malaise

• confusion

• irritability

What does CURB-65 stand for?

• confusion

• urea >7mmol/L

• respiratory rate >30 

• low blood pressure 

• age ≥65

What CURB-65 score indicates mild pneumonia?

• 0–1, with >1% mortality—suitable for community management and oral antibiotics.

What CURB-65 score indicates moderate pneumonia?

• Score of 2, with 1–10% mortality—consider hospital management or close follow-up in the community.

What CURB-65 score indicates severe pneumonia?

• ≥3, with ≥10% mortality—requires hospital management.

What imaging is used to confirm pneumonia diagnosis?

• chest X-ray showing consolidation, ideally within 4 hours of admission

What blood tests support pneumonia diagnosis?

• Inflammatory markers and possibly blood cultures

When is a CT scan indicated in pneumonia?

• If there’s a poor response to treatment.

What additional test helps identify viral causes of pneumonia?

• Viral swabs

What antibiotics are commonly used to treat CAP and how many days is the treatment?

• Amoxicillin

• Doxycycline

• Clarithromycin.

• 5 days of treatment 

Which antibiotics are used for severe CAP or CURB ≥ 3?

• Co-amoxiclav

• Tazocin

• Meropenem.

What is the gaol after initial IV antibiotic therapy and when should effectiveness be reviewed?

• switch to oral antibiotics 

• effectiveness reviewed after 48hrs 

Name four supportive treatments for CAP.

• Oxygen therapy, fluids, paracetamol, analgesia.

What is bronchiectasis?

• condition where the airways in your lungs are damaged and produce a lot of phlegm (mucus)

What structural change defines bronchiectasis?

• permanent dialtion and thickening of smaller airway

What tissue components are damaged in bronchiectasis?

• Elastin, muscle, and cartilage.

What cellular changes occur in bronchiectasis?

• infiltrates in cell walls and enlarged lymph nodes 

What is the “vicious cycle hypothesis” in bronchiectasis?

• Infection → inflammation → damage → progressive lung disease → repeat

What are the key features seen in a bronchiectatic airway?

• Loss of cilia, increased mucus, destruction of airway wall.

What are the types of bronchiectasis airway?

• cylindrical 

• cystic/saccular 

• varicose 

• traction

What is the appearance of cylindrical bronchiectasis?

• Tram-track’ appearance with straight and regular outlines.

How does cystic/saccular bronchiectasis appear?

• Ballooned airways with honeycomb pattern and air-fluid levels

What characterizes varicose bronchiectasis?

• dilated segments with areas of constriction.

What causes traction bronchiectasis?

• Fibrosis or scarring of the lung parenchyma.

What is the clinical presentation of bronchiectasis?

• chronic cough

• sputum production

• frequent chest infections

  • colonisation

• minor haemoptysis

• breathlessness

• crackles on auscultation

What are the exacerbation features of bronchiectasis?

• Increased SOB

• Increase in sputum

• Increase in cough

• Changes in sputum – colour, consistency

• Fatigue and/or fever >38o C

  
  

Name two mucolytics used in bronchiectasis?

• Carbocisteine and NACSYS.

When is azithromycin used in bronchiectasis?

• for patients with ≥3 exacerbations per year, initiated by a respiratory specialist.

Name three inhaled therapies used in bronchiectasis?

• β₂ agonists (SABA, LABA), LAMA, colomycin

What is the role of hypertonic saline in bronchiectasis?

• to improve mucus clearance, under specialist supervision.

How often should respiratory physiotherapy be performed in stable bronchiectasis?

• Twice daily.

What are the benefits of regular respiratory physiotherapy?

• Improves sputum expectoration, cough-related health, quality of life, and exercise capacity.

When should prednisolone doses be weaned and what is the regimen?

• if 2 or more short courses are used within 12 months.

• reduce by 5mg every 3 days

What are the benefits of prednisolone?

• reduced inflammation by:

  • supressess movement of leukocytes 

  • reduce capillary permeability 

  • reduce immune system response 

Side effects of prednisolone?

• adrenal suppression 

• cushing syndrome 

• increase appetite/weight gain 

• impaired diabetic control

• increased risk of infection 

• osteoporosis

• sleep disorders

What is the function of mucolytics?

• break down of chemical structure of mucus to aid clearance

What is the daily dose, CI and side effect of carbocisteine?

• 2.25 g daily in divided doses (3 × 750 mg); reduce to 1.5 g after 6 months if tolerated.

• CI - active peptic ulcer

• Side effect - GI upset

What is the dose, form, side effects of NACSYS and what precaution is needed?

• 600mg OD as an effervescent tablet 

• use in caution in asthma 

• side effects - GI upset and headaches 

When should NACSYS therapy be initiated?

• secondary care 

What drug class is montelukast?

• leukotriene receptor antagonist

  • blocks leukotriene receptors to inhibit bronchoconstriction

What is the adult dose of montelukast?

• 10mg once daily in evening