Topic Summary: Respiratory 1

TOPIC SUMMARY: RESPIRATORY

ASTHMA AND COPD
• Asthma: trigger factors (dust mite, pollen, animals, smoking, • Long-acting (duration of action: 12hr) :
respiratory tract infections, exercise, allergens, sensitivity to o Eformoterol (Oxis, Foradile) 1 puff bd (onset 1-3min)
foods/chemicals/preservatives, drugs such as NSAIDs, beta blockers, o Salmeterol (Serevent) 1 puff bd (onset 10-20min)
complementary medicines) o Indacaterol (Onbrez) 1 puff d
• Symptoms of asthma: wheezing, difficulty in breathing, chest tightness,
nocturnal coughs Other practice points (long-acting):
• COPD (chronic obstructive pulmonary disease): airway obstruction due • Combination products available
to inflammatory response of lungs that is not always reversible. o Eformoterol + Budesonide (Symbicort) – can be used for acute
• Symptoms of COPD: emphysema, mucus, airway damage and relief in adults with asthma who are using inhaled
narrowing of airways. Combination of asthma + chronic bronchitis + corticosteroilds.
emphysema and airway obstruction. o Salmeterol + Fluticasone (Seretide) 1 puff bd

DRUGS FOR ASTHMA AND COPD Anticholinergic bronchodilators

Beta2 agonist bronchodilators Mode of action: inhibits bronchoconstriction
Mode of action: stimulation of beta2 receptors causes bronchodilation • Short-acting: Ipratropium (Atrovent, Ipratrin) - onset 2hr; duration of
• Short-acting (onset 5min; duration of action 3hr): action 6hr; use QID
o Salbutamol (Ventolin, Asmol, Airomir) 1-2 puffs qid prn • Long-acting: Tiotropium (Spiriva) - onset 30min; duration of action
o Terbutaline (Bricanyl) 1-2 puffs qid prn 24hr; use 1 daily

Other practice points (short-acting): Corticosteroids

• Acute asthma, symptom relief , prevention of exercise-induced asthma Mode of action: reduce bronchial inflammation
• Use with precaution in hypertension, heart failure, arrhythmias, • Inhaled corticosteroids (preventers in asthma):
diabetes o Beclomethasone (Qvar) 1 bd
• Side effects (high doses): tremor, palpitations, headache o Budesonide (Pulmicort) 1 bd

Copyright © The Medicine Box 2013

Topic Summary: Respiratory 2

o Ciclesonide (Alvesco) 1 d Leukotriene receptor antagonists

o Fluticasone (Flixotide) 1 bd Mode of action: relaxation of smooth muscle and reduction of inflammation
Side effects: hoarse voice, oral thrush • Montelukast (Singulair) 1 n
Counselling: rinse mouth with water after inhalation Side effects: headache, abdominal pain, diarrhoea

• Intranasal corticosteroids (allergic rhinitis): Xanthine bronchodilator

o Budesonide (Rhinocort) 1-2 bd Mode of action: relax smooth muscle and increase diaphragm contractility
o Fluticasone furoate (Avamys) 1-2 d • Theophylline (Nuelin) 1 d cc
o Mometasone (Nasonex) 1-2 d Side effects: low therapeutic index
monitoring; nausea, vomiting,
o Triamcinolone (Telnase) 2 d diarrhoea, headache, insomnia, anxiety, tremor, palpitations
Side effects: sneezing, nasal irritation, nosebleeds
Other practice points:
• Oral corticosteroids: prednisolone/prednisone • Concentration monitoring at initiation, changes with drug regimen,
o Counselling: once daily in the morning (evening dose can fever or side effects suspected, changes in smoking habits
cause sleep disturbance); short-term treatment (long term
treatment of 2+ weeks can cause adrenal suppression and
rebound withdrawal symptoms if abrupt cessation)

Cromolyns
Mode of action: chloride channel blockers that stabilise mast cells; block
allergen-induced bronchoconstriction
• Inhalation (asthma prevention):
o Nedocromil (Tilade) 1 qid
o Sodium cromoglycate (Intal) 1 bd to qid
Side effects (inhaled): bronchospasm and throat irritation; headache
• Intranasal (allergic rhinitis): sodium cromoglycate (Rynacrom)
• Eye drops (allergic conjunctivitis): sodium cromoglycate (Opticrom,
Cromolux)

Copyright © The Medicine Box 2013

Topic Summary: Respiratory 3

TREATMENT OF ASTHMA ATTACKS

Mild
Short-acting beta2 agonist
monitor for 1 to 24 hours after attack

Moderate
Oxygen therapy
short-acting beta2 agonist
oral corticosteroids AND start
inhaled corticosteroids
monitor with chest x-ray

Severe
HOSPITAL admission immediately
oxygen therapy
short-acting beta2
agonist + ipratropium
oral or i.v. corticosteroids AND start inhaled
corticosteroids
adrenaline for anaphylaxis or cardiorespiratory arrest

monitor with chest x-ray and hypokalaemia

Copyright © The Medicine Box 2013

Topic Summary: Respiratory 4

TABLE: INHALED MEDICATIONS FOR ASTHMA AND COPD

Class Generic name Brand name Form Dose Other comments

Salbutamol Airomir MDI, Autohaler 1-2 q4h prn • Prime inhalers when using it for the first time and also if it
hasn’t been used for 5 days or more.
Asmol MDI, nebules (severe 1-2 q4h prn • Dilute nebulising solution with sodium chloride 0.9% if using
Ventolin acute asthma) alone.
Relievers

Terbutaline Bricanyl Turbuhaler 1 q4h to q6h prn • Maximum 8 puffs (children) or 12 puffs (adults) in 24 hours

Ipratropium Atrovent MDI, nebules (severe 2 tid to qid prn • Dilute nebulising solution with sodium chloride 0.9% if using
Ipratrin acute asthma) alone.
• Avoid mist to get into the eyes.

Ciclesonide Alvesco MDI 1-2 d or bd • Rinse mouth with water after inhalation with all inhaled
corticosteroid preparations. Failure will result in hoarse voice,
Corticosteroid preventers

oral thrush, sore throats, and infections.

Fluticasone Flixotide MDI, accuhaler, nebules 1-2 bd
propionate

1-2 bd to qid
Budesonide Pulmicort Turbuhaler, respules

1 bd
Beclomethasone Qvar MDI, autohaler

Copyright © The Medicine Box 2013

Topic Summary: Respiratory 5

Class Generic name Brand name Indication Dose Other comments

Combination products

Budesonide + Symbicort Turbuhaler 1-2 bd for maintenance. • Acute relief: may admin 1 additional inhalation to control
Eformoterol symptoms followed by another inhalation if symptoms persist.
• Maximum 8 inhalations per day

Fluticasone + Seretide MDI, accuhaler 1 bd • Rinse mouth with water after inhalation.
Salmeterol
Non-steroid preventers

Sodium Intal MDI, nebules 2 bd to qid (MDI) • Clean mouthpiece daily and air dry for 24 hours to prevent
cromoglycate 1 qid (nebules) blockage of nozzles. Alternate with extra mouthpiece.

Nedocromil Tilade MDI 2 qid then 2 bd

Eformoterol Foradile Aerolizer 1-2 bd

Controllers
Symptom

Oxis Turbuhaler

Salmeterol Serevent Accuhaler 1-2 bd

Indacaterol Onbrez Breezhaler 1d • SE: nasopharyngitis, cough, URTI, headache, muscle

COPD

spasms.

Tiotropium Spiriva Handihaler 1d • Place capsule into device.

Copyright © The Medicine Box 2013

Topic Summary: Respiratory 6

CROUP DECONGESTANTS
• Symptoms: a barking cough and hoarseness of voice due to Mode of action: vasoconstriction in nasal mucosa
inflammatory oedema within the sub-glottis triggered by an acute viral • Intranasal:
infection. o Oxymetazoline (Dimetapp, Drixine, Logicin, Sudafed)
• Treatment: o Phenylephrine (Nyal)
o Prednisolone (Predmix, Panafcortelone) 1mg/kg orally for 2 o Tramazoline (Spray-Tish)
days o Xylometazoline (Flo, Otrivin)
Counselling: to prevent rebound congestion, do not use for more than
PERTUSSIS (WHOOPING COUGH) 5 days.
• Whooping Cough: contagious bacterial infection causing persistent
cough for more than 2 weeks. • Oral: pseudoephedrine (Sudafed), phenylephrine (Sudafed)
• Treatment: Side effects (oral): increased blood pressure, insomnia, agitation,
o Azithromycin (Zithromax) 500mg daily for 4 days OR anxiety
o Clarithromycin (Klacid, Kalixocin) 500mg bd for 7 days OR
o Erythromycin (EES, E-mycin) 400mg qid for 7 days

INFLUENZA (FLU)
• Start treatment early (within 48 hours of symptom onset).
• Treatment:
o Oseltamivir (Tamiflu) 75mg bd for 5 days OR
o Zanamivir (Relenza) 10mg inhalation for 10 days

Copyright © The Medicine Box 2013

Topic Summary: Respiratory 7

References

Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2013

eTG Complete. Melbourne: Therapeutic Guidelines Ltd; 2013

eMIMS 5.0; MIMS Australia Pty Ltd; Sydney; 2013

Useful resource:

Asthma and COPD medications chart

http://www.nationalasthma.org.au/health-professionals/primary-care-resources/asthma-copd-medications-chart

Copyright © The Medicine Box 2013

All rights reserved. Apart from any use permitted under the Copyright Act 1968 of Australia, material in
this publication must not be reproduced or stored in any way without prior written permission of the
publishers.

While every effort has been made to ensure this publication is as accurate as possible, the Medicine
Box team does not accept any responsibility for any loss which the user may suffer as a result of errors
or inaccuracy of information contained in this publication.

Copyright © The Medicine Box 2013