3 RESPIRATORY SYSTEM
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1 3 RESPIRATORY SYSTEM 3.01 ANTIASTHMATICS 3.01a BETA 2 AGONIST ASTHMA, CHRONIC BRONCHITIS & EMPHYSEMA Salbutamol Inhaler 100ug/dose [Albuterol] (Ventolin) Salbutamol Sulphate Respirator Solution 0.5% (5mg/ml), Nebules 1mg & 2.5mg (Ventolin) [Albuterol] Acute and intermittent episodes of wheezing and asthma, ug (1-2 puffs) up to 3-4 times daily; child 100ug (1 puff) increased to 200ug (2 puffs) up to 4 times daily if needed. Adult & child > 18 mth, 2.5-5mg up to q6h during acute, severe asthma. Dilute 0.5% (5mg/ml) solution with 3mls of NS before administration. If dosing is needed more than once daily in beta 2 agonists alone regimen, consider adjunct therapy. Inadequate response may be due to poor inhalation technique. An aerochamber or spacer device may be useful. Dry powder devices such as turbuhalers or accuhalers are available for patients with co-ordination difficulties, but should be considered after MDIs and spacers have been tried. S/E (minimal with inhaled preparations): tachycardia, tremor, nervousness, hypokalaemia, muscle cramp, and impaired glucose tolerance. See Appendix I for the choice of inhaler devices for children. 3.01b OTHER BRONCHODILATORS Epinephrine Inj 1mg/ml [Adrenaline 1:1000] Anaphylaxis: undiluted SC/IM, adult 500ug (0.5ml), 6-12 yo 250ug (0.25ml), 6 mth-6 yo 120ug (0.12ml), < 6 mth 50ug (0.05ml). 20
2 Ipratropium Bromide Inhaler 20ug/dose (Atrovent Metered Aerosol) Ipratropium Bromide Nebuliser Solution % (250ug/2ml) & 0.025% (500ug/2ml) (Atrovent) For chronic obstructive pulmonary disease or chronic asthma: adult, 20-40ug (1-2 puffs) 3-4 times daily, max 80ug (4 puffs) 4 times daily; child < 6 yo 20ug (1 puff) and 6-12 yo 20-40ug (1-2 puffs), 3 times daily ug (0.4-2ml) up to 4 times daily; child 3-14 yo ug up to three times daily. Ipratropium is useful for bronchitis or emphysema, and in the elderly and in young children CORTICOSTEROIDS PROPHYLAXIS OF ASTHMA Beclomethasone Dipropionate Inhaler 100ug/dose (Becotide 100) Beclomethasone Dipropionate Inhaler 250ug/dose (Becloforte) Budesonide 50ug/dose Inhaler, or 200ug/dose Turbuhaler/Inhaler (Pulmicort/Inflammide) Prednisolone Tablet 5mg, 25mg & 50mg NF Adult 200ug (2 puffs) twice daily, if severe max 800ug (8 puffs) daily then reduced; child 100ug (1 puff) 2-4 times daily or ug (1-2 puffs) twice daily. Adult 500ug (2 puffs) twice daily or 250ug (1puff) 4 times daily, max 500ug (2 puffs) 4 times daily. Adult: 200ug twice daily, reduced if well-controlled to 200ug daily, in severe asthma increased to max 1.6mg daily; child 50ug twice daily, in severe asthma increased to max 800ug daily. For acute severe asthma, adult 30-60mg orally for 1-3 days; child < 1 yo 1-2mg/kg daily, 1-5 yo 20mg daily, for 1-3 days. 21
3 REGULAR DOSING IS ESSENTIAL. Consider aerochamber or spacer devices to minimise side effects and increase dosing efficiency. Administering the bronchodilator before the corticosteroid inhalation preparation may enhance dosing. S/E: hoarseness, candidiasis of mouth and throat (reduce by using spacer device, or rinsing/wiping mouth with water after inhalation), glaucoma, paradoxical bronchospasm, Suppression of adrenal cortex may occur at beclomethasone doses of over 1500ug daily ANTIHISTAMINES & ANTIALLERGICS Cetirizine HCL Tab 10mg (Zyrtec) Chlorpheniramine Maleate Tab 4mg & Suspension 2mg/5ml (Piriton) Diphenhydramine Inj 50mg/ml (Benadryl) Hydroxyzine HCl Tab 25mg (Atarax) NF Adult and child > 6 yo, 10mg daily or 5mg twice daily; Child 2-6 yo, for hay fever, 5mg daily or 2.5mg twice daily. Child 1-2 yo 1mg twice daily; 2-5 yo 1mg, 6-12 yo 2mg, adult 4mg, given 3-4 times daily. Hypersensitivity reactions, motion sickness, antidyskinetic: adult IM/IV mg, max daily dose 400mg; child >10kg, 5mg/kg/DAY IM/IV; max 300mg/DAY. Pruritus, initially 25mg at night, up to 3-4 times daily. Loratadine Tab 10mg (Clarityne) 10mg daily. Loratadine 5mg/5ml Syrup (Clarityne), 100ml Child 2-12 yo, <30kg, 5ml daily; >30kg, 10ml daily. 22
4 Promethazine HCl Inj 25mg/ml (Phenergan) Promethazine HCl Tab 25mg & Syrup 5mg/5ml (Phenergan) IM 25-50mg, max 100mg. Child 5-10 yo mg. Slow IV in emergencies 25-50mg, max 100mg (max rate 25mg/min). Inject IM undiluted deep into a large muscle mass. Inject slow IV undiluted or dilute 25mg with 10ml WFI over 1-2 min. Adult, 25-50mg daily in divided doses or single dose at night; max 75mg daily. Child, 1-5 yo 5-15mg daily, 6-10 yo 10-25mg daily. Antihistamines may cause drowsiness, advice patients not to drive or operate machinery if affected. They potentiate the effects of alcohol COUGH & COLD REMEDIES Diphenydramine Expectorant Paediatric (Benadryl 1:2) Diphenhydramine 14mg Compound Adult Expectorant (Benadryl) NF Child 2-6 yo 6.25mg every 4-6 hours, max 37.5mg/DAY; 6-12 yo 12.5mg q4-6h, max 75mg/DAY. NF Adult 5-10ml, child 1-5 yo 2.5ml, 6-12 yo 5ml, usual 3-4 times daily for chesty cough. 23
5 *Pholcodine Linctus 5mg/5ml (Pavachol-D) For unproductive and persistent cough: adult 5-15ml (1-3 teaspoonfuls) up to 4 times daily; child 6-12 yo 5ml (1 teaspoon) up to 4 times daily, 3-5 yo 5ml up to 3 times daily, 1-2 yo 2.5ml up to 4 times daily. Pholcodine may cause constipation, monitor chronic use also for abuse. DRUG-INDUCED DRY COUGHS: All therapeutic aerosols may cause coughs by local irritant effect, ACE inhibitors can also produce the adverse effect of persistent dry cough. Other factors may include occupational or environmental exposure to irritant aerosolised chemicals or dust particles, consider asthma or allergic reactions SYSTEMIC NASAL DECONGESTANTS Pseudoephedrine Hydrochloride Tab 60mg (Sudafed) Nasal congestion, adult 60mg (one tablet) up to 4 times daily, child 2-6 yo 15mg (quarter tablet) 3 times daily, 6-12 yo 30mg (half tablet) 3 times daily. Psuedoephdrine should be used with caution in diabetes, hypertension, hyperthyroidism, and ischaemic heart disease, and AVOIDED in patients taking monoamine oxidase inhibitors. NOTE. For Topical Nasal Decongestants, and Throat and Mouth Preparations, see Chapter 10 Ear, Nose and Throat Section Topical Nasal Preparations & Section Medicines for Oral Ulceration & Inflammation. 24
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