BNF CHAPTER 3: RESPIRATORY

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3.1 BRONCHODILATORS BNF CHAPTER 3: RESPIRATORY 3.1.1.1 SELECTIVE BETA 2 -AGONISTS Short acting Salbutamol 100 micrograms/actuation aerosol inhaler 100 micrograms/actuation breath-actuated (e.g., Easi-Breathe ) 200 micrograms/dose Accuhaler dry powder device 2mg/5mL syrup 4mg m/r, 8mg m/r capsules 2.5mg/2.5mL nebuliser solution 5mg/2.5mL nebuliser solution 500 micrograms/ml injection 5mg/5mL solution for IV infusion Terbutaline 500 micrograms/dose Turbohaler dry powder device 500 micrograms/ml injection Longer acting (LABA) Formoterol/eformoterol fumarate 12 micrograms/dose Turbohaler dry powder device Salmeterol 25 micrograms/actuation aerosol inhaler 50 micrograms/dose Accuhaler dry powder device Indacaterol (licensed for COPD) 150mcg, 300mcg Onbrez Breezhaler (powder capsule) LABA are indicated as an option for introduction at step three of the British Thoracic Society/SIGN guidelines for chronic asthma in adults. If they are used at night they can be useful for early morning bronchospasm. They are not for immediate relief of acute asthma attacks. It is important that existing inhaled corticosteroid therapy is not reduced or withdrawn. Formoterol in combination with budesonide, Symbicort SMART, may be used as both regular preventative therapy and reliever therapy, for mild to moderate asthmatics. To be initiated by respiratory team only, please consult pharmacists or respiratory team for advice (see section 3.2 for preparations).

3.1.2 ANTIMUSCARINIC BRONCHODILATORS Ipratropium bromide 20 micrograms/actuation aerosol inhaler 250 micrograms/ml unit-dose vials 500 micrograms/2ml unit-dose vials Tiotropium (licensed for COPD) 18 micrograms/dose dry powder capsule 1 st line option 2.5mcg Respimat inhaler seek respiratory opinion before initiating. Not to be used with ipratropium discontinue if ipratropium nebulisers commenced as inpatient Antimuscarinic bronchodilators should be considered when nebulised salbutamol alone fails to adequately relieve bronchospasm. 3.1.3 THEOPHYLLINE The brands of modified release theophylline have different release characteristics and are not interchangeable. Preparations should be always be prescribed by BRAND (see preparations below). Theophylline 200 mg m/r tablets } (Uniphyllin ) 300mg m/r tablets } 400mg m/r tablets } 60mg m/r capsules } Slo-phyllin 125mg m/r capsules } 250mg m/r capsules} 175mg mr tablets } Nuelin SA 250mg m/r tablets } Aminophylline 250mg/10mL injection secondary care use only 225mg m/r tablets 350mg mr tablets

Guidelines for aminophylline infusion for patients with severe acute asthma For patients who require intravenous aminophylline and have been receiving oral theophylline preparations, the intravenous loading dose should be omitted. They should be started on an intravenous maintenance dose. Loading dose 250 to 500mg ( 5mg/Kg) over 20 minutes Maintenance dose 500 micrograms/kg/hour adjust to plasma theophylline concentration (See dosing charts below) Aminophylline Loading dose (5mg/kg) (See table right) Add the loading dose to 100mL bag of sodium chloride 0.9% and infuse at a rate of 300mL/hour until empty Patient s weight (kg) Aminophylline Loading Dose (mg) 50 250 55 275 60 300 65 325 70 350 75 375 80 400 85 425 90 450 95 475 100 500 Aminophylline Maintenance infusion (500mcg/kg/hr) Withdraw 40mL from a 1litre bag of sodium chloride 0.9% and to it add 4 x 250mg/10mL amps of aminophylline injection to give a 1mg/1mL solution Using an infusion pump commence infusion at a rate of 500micrograms/kg/hr see chart below for conversion Adjust rate according to plasma theophylline levels/clinical response/patient tolerability (Higher concentrations (up to 25mg/mL) may be used in fluid restricted patients)

Patient s weight (kg) Aminophylline maintenance infusion dose (mg/hr) Aminophylline maintenance infusion rate (ml/hr of a 1mg/ml solution) 50 25 25 55 27.5 27.5 60 30 30 65 32.5 32.5 70 35 35 75 37.5 37.5 80 40 40 85 42.5 42.5 90 45 45 95 47.5 47.5 100 50 50 Guidelines for monitoring theophylline treatment and theophylline sampling times Intravenous infusion (aminophylline): Take blood sample 4 to 6 hours after starting infusion. Monitor every 24 hours whilst on the infusion. Time to steady state is 48 hours and levels should not be taken before then unless an IV loading dose has been given. Oral therapy: Slow release products: Take blood sample pre-dose. Time to steady state is 48 hours.

3.1.4 COMPOUND BRONCHODILATOR PREPARATIONS In general, patients are best treated with single-ingredient preparations, such as a selective beta 2 agonist (3.1.1.1 SELECTIVE BETA2-AGONISTS) or ipratropium bromide (. 3.1.2 ANTIMUSCARINIC BRONCHODILATORS), so that the dose of each drug can be adjusted. This flexibility is lost with combination products. Bronchodilators are only indicated where there are signs of bronchospasm. Combination products should only be considered for patients stabilised on individual components in the same proportion. Please bear in mind that the cost of a combination product may be significantly more than if the individual components are prescribed separately. Combivent Ipratropium bromide 500micrograms, salbutamol 2.5mg/2.5mL nebuliser solution administered as separate components at ward level as combination product not stocked at COCH

3.2 CORTICOSTEROIDS Beclometasone Qvar 50, 100 micrograms/actuation aerosol inhaler MDI 50, 100 micrograms/actuation breath actuated inhaler (e.g., Easi-Breathe Autohaler ) (licensed for adults and children >12 years) Clenil modulite 50, 100, 200, 250 micrograms/actuation aerosol inhaler MDI (licensed for adults and children <12years [100-200 micrograms twice daily]) Budesonide 500 micrograms/2ml nebuliser solution 1mg/2mL nebuliser solution 100, 200, 400 micrograms/dose Turbohaler (licensed for adults and children >5 years) Fluticasone 50, 125, 250 micrograms/actuation aerosol inhaler 50, 100, 250, 500 micrograms/blister Accuhaler (dry powder) (licensed for adults and children >4 years [max 200 micrograms twice daily]) There are different dose equivalences between the different brands of CFC free beclometasone inhalers. Therefore they should be prescribed by brand name. Guidelines for the routine use of inhaled corticosteroids (ICS) in adults Beclometasone is the inhaled corticosteroid of choice when a low dose is indicated, 200 to 800 micrograms daily (100 to 400 micrograms daily if using Qvar). Qvar should be considered first choice if a CFC free inhaler is required. Alternative corticosteroids may be considered for those patients requiring higher doses on advice of the respiratory team only. None of the inhaled corticosteroids currently available are licensed for use alone in the treatment of COPD. The CSM issued advice in May 1998 about the safety of inhaled corticosteroids. Once the condition being treated is controlled, the dose of the inhaled corticosteroid should be titrated to the lowest dose at which effective control is maintained. Prolonged treatment with high doses may lead to significant adrenal suppression.

Compound preparations Compound corticosteroid preparations can remove flexibility in dosing. They are usually considered when the patient is stabilised on the two separate components in the proportions contained in the combination device. Combination inhalers containing a steroid and long-acting beta-2 agonist (LABA) are useful in ensuring that beta-2 agonists are not used without concomitant inhaled steroid for management of asthma. Fostair MDI Beclometasone / formoterol 100 micrograms / 6 micrograms Symbicort Turbohaler Budesonide / formoterol 100 micrograms / 6 micrograms 200 micrograms / 6 micrograms 400 micrograms / 12 micrograms Seretide MDI Fluticasone / salmeterol 50 micrograms / 25 micrograms 125 micrograms / 25 micrograms 250 micrograms / 25 micrograms Accuhaler 100 micrograms / 50 micrograms 250 micrograms / 50 micrograms 500 micrograms / 50 micrograms Symbicort SMART may be used as both regular preventative therapy and reliever therapy, for mild to moderate asthmatics. To be initiated by respiratory team only, please consult pharmacists or respiratory team for advice. See NICE guidance TA 138 Asthma - inhaled corticosteroids for the treatment of chronic asthma in adults and children aged 12 years and over.

3.3.1 CROMOGLICATE AND RELATED THERAPY Not recommended for routine use 3.3.2 LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast 10mg tablets 4mg chewable tablets/granules 5mg chewable tablets Zafirlukast 20mg tablets Consider at step 3 of guidelines. Their effectiveness should be assessed after 6-12 weeks and discontinued if no improvement. They may be of benefit in exercise induced asthma and concomitant allergic rhinitis. Churg-Strauss syndrome is a very rare side effect of leukotriene receptor antagonists and usually occurs following oral corticosteroid withdrawal or reduction. CSM advice: Prescribers should be alert to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications or peripheral neuropathy.

3.4 ANTIHISTAMINES, HYPOSENSITISATION, AND ALLERGIC EMERGENCIES 3.4.1. ANTIHISTAMINES Sedating antihistamines First choice Chlorphenamine 4mg tablets 2mg/5mL syrup 10mg/mL injection Second choices Alimemazine (trimeprazine) 10mg tablets 7.5mg/5mL syrup 30mg/5mL syrup Promethazine 10mg, 25mg tablets 5mg/5mL elixir 25mg/mL, 50mg/2mL injection Non-sedating antihistamines Cetirizine 10mg tablets 5mg/5mL oral solution Loratadine 10mg tablets 5mg/5mL syrup NB: levocetirizine and desloratadine remain more expensive than cetirizine and loratadine. There is a lack of evidence confirming clinical benefit over the older preparations and therefore they remain non-formulary. Fexofenadine 120mg,180mg tablets 3.4.2 ALLERGEN IMMUNOTHERAPY Omalizumab Injection 75mg,150mg Please click on the following link for guidance on the place of omalizumab in the Management of severe persistent allergic asthma

3.4.3 ALLERGIC EMERGENCIES Adrenaline 1 in 1,000 1mg/mL injection Adrenaline 1 in 10,000 100 micrograms/ml injection Jext (adrenaline 1 in 1000) 150mcg in 1.4ml Auto-injector device (Jext is the brand of choice) 300mcg in 1.4ml Auto-injector device

3.5 RESPIRATORY STIMULANTS AND PULMONARY SURFACTANTS SECONDARY CARE USE ONLY Doxapram 2mg/mL in glucose 5% solution for intravenous infusion (500mL) (20mg/mL injection for use in ITU and fluid restricted patients only) Doxapram infusion administration guidelines indication: In adult respiratory failure (hypercapnia in acute on chronic respiratory failure) non-invasive positive pressure ventilation (NIPPV) is the treatment of choice. Doxapram may be used while patients await to start NIPPV. Doxapram infusion with oxygen therapy is used for up to 24 hours, only in patients who fail to tolerate NIPPV whilst an alternative mode of therapy is investigated. dose: 1.5 to 4mg/minute as continuous IV infusion, adjusted according to response. See regime below. Regime for acute respiratory failure using doxapram 2mg/ml in glucose 5% infusion (500mL) Time from start of infusion Dose Infusion rate 0-15 mins 15-30 mins 30-60 mins 60 mins onwards 4mg/min 3mg/min 2mg/min 1.5mg/min 120mL/hr for 15 mins 90mL/hr for 15 mins 60mL/hr for 30 mins 45mL/hr continuously Monitoring: Frequent arterial blood gasses and ph to ensure correct dosage.

3.7 MUCOLYTICS Carbocisteine 375mg caps 250mg/5mL syrup Place of mucolytics in the management of COPD Consider in people with a chronic productive cough, not for routine use in prevention of exacerbations. Commence carbocisteine 2.25g daily in divided doses e.g. caps; 750mg tds, syrup; 15mL tds for 4 weeks THEN REVIEW If no improvement in symptoms DISCONTINUE If symptomatic improvement, continue on maintenance dose of 1500mg daily: caps; 375mg qds or 750mg bd, syrup; 10ml tds Sodium chloride 0.9% Hypertonic saline 7% (Nebusal ) Secondary care use - on advice of respiratory team only. 10ml injection for routine nebuliser use 4ml nebuliser solution up to twice daily in conjunction with physiotherapy Temporary irritation e.g., coughing, hoarseness or reversible bronchoconstriction may occur with hypertonic saline. Using an inhaled bronchodilator e.g., salbutamol before treatment may minimise such adverse effects. Dornase alpha 2.5mg/2.5ml nebuliser solution (Cystic fibrosis only)

3.9 COUGH PREPARATIONS Use of cough suppressants is not recommended long-term, address other causes e.g. asthma, gastro-oesophageal reflux, chest infection and limit use where possible. Simple linctus Demulcent Sugar free preparation also available Pholcodine 5mg/5mL mixture SF Cough suppressant Codeine 15mg/5mL linctus Cough suppressant Methadone 2mg/5mL linctus CD For intractable cough in patients with lung cancer secondary care and hospice use only