Chapter 3 – Respiratory System
OBSTRUCTIVE AIRWAYS Tiotropium (Spiriva, Braltus)
DISEASE Indications:
1. Maintenance of COPD
Inhaled Antimuscarinics 2. Severe asthma (Spiriva)
- aclidinium bromide with formoterol (Duaklir),
glycopyrronium with indacaterol (Ultibro MHRA/CHM: with Braltus, there’s a risk of
Breezhaler), ipratropium with salbutamol inhalation of the capsule if placed in the
(Combivent), tiotropium with olodaterol (Spiolto) mouthpiece of the inhaler. Pts are at risk of
aspiration or airway obstruction. Hence, Pts
!: bladder outflow obstruction, prostatic should store caps in the bottle provided (not in
hyperplasia, angle-closure glaucoma the inhaler) and always check the mouthpiece
before inhaling
SEs: arrhythmias, cough, dry mouth, epistaxis,
constipation, palpitations, glaucoma, urinary Umeclidinium (Incruse Ellipta)
disorders, blurred vision
Indication: maintenance of COPD
Aclidinium bromide (Eklira) Dose (powder inhalation): 55mcg OD
Indication: maintenance of COPD Umeclidinium with vilanterol (Anoro Ellipta)
Dose (powder inhalation): 375mcg BD Indication: maintenance of COPD
Glycopyrronium bromide (Seebri Breezhaler) Dose (powder inhalation): 1 inhalation OD
Indication: maintenance of COPD X: severe pre-eclampsia
Dose (powder inhalation): 1 cap (55mcg) OD !: hypokalaemia may be enhanced with
concomitant use of theophylline, corticosteroids,
SEs: increased risk of infection, insomnia, diuretics and by hypoxia
hyperglycaemia, throat irritation
M: plasma-potassium concentration and monitor
Ipratropium bromide (Atrovent, Inhalvent) blood glucose in diabetics due to risk of
hyperglycaemia and ketoacidosis
Indications:
1. Reversible airways obstruction Selective Beta-2 Adrenoceptor
2. Airways obstruction in COPD
Agonists
3. Acute bronchospasm
4. Severe or life-threatening asthma X: severe pre-eclampsia
PK: maximal effect occurs 30-60mins post use; !: diabetes (risk of hyperglycaemia and
duration of action is 3-6hrs and bronchodilation ketoacidosis), hypertension, hyperthyroidism,
can be maintained with treatment 3 times daily hypokalaemia, QT-interval prolongation
!: angle-closure glaucoma reported with nebulised SEs: hyperglycaemia, palpitations, tremor
use, especially when given with nebulised
salbutamol M: in severe asthma, monitor plasma-K conc. In
diabetics, monitor blood glucose levels
SEs: corneal oedema
Advice: when used by inhalation, the dose,
X: H/O to atropine or its derivatives frequency and max number of inhalations in 24hrs
Advice: risk of dizziness and vision disorders should be stated explicitly.
hence take caution with skilled tasks
, Chapter 3 – Respiratory System
Selective Beta-2 Adrenoceptor dose. Any deterioration in symptoms following
Agonists (Long-Acting) initiation must be reported
- bambuterol (Bambec), indacaterol (Onbrez Selective Beta-2 Adrenoceptor
Breezhaler), olodaterol (Striverdi Respimat) Agonists (Short-Acting)
CHM: for chronic asthma, long-acting beta-2 M: in labour, monitor BP, pulse rate (should be
agonists should be added only if regular use of <120bpm), ECG (discontinue if signs of myocardial
standard ICS has failed to control symptoms, be ischaemia develop), blood glucose and lactate
introduced at a low dose, not be initiated in Pts concentrations, fluid status (discontinue if
with rapidly deteriorating asthma, not be used for pulmonary oedema occurs and initiate diuretics)
the relief of exercise-induced asthma symptoms
Advice: for inhalation by aerosol or dry powder,
unless regular ICS are also used and be
do not exceed the prescribed dose. If a previously
discontinued in the absence of benefit.
effective dose fails to provide at least 3hrs of
PK: duration of action is approx. 12hrs relief, obtain advice. For inhalation by nebuliser,
the dose given is much higher than given by an
Formoterol fumarate (Easyhaler, Oxis inhaler hence it’s dangerous to exceed the
Turbohaler, Atimos Modulite) prescribed dose.
Indications: PK: duration of action is 3 to 5 hours
1. Reversible airways obstruction
Salbutamol (Easyhaler, Ventolin
2. Chronic asthma in Pts who regularly use an Accuhaler/Evohaler, Salamol)
inhaled corticosteroid
Indications:
3. COPD 1. Asthma
4. Relief of bronchospasm 2. Prophylaxis of allergen- or exercise-induced
bronchospasm
5. Prophylaxis of exercise-inhaled bronchospasm
3. Uncomplicated premature labour (between
Advice: Pts must not exceed prescribed dose and 22-37 weeks of gestation)
report any deterioration in symptoms following
initiation of Tx Terbutaline (Bricanyl)
Salmeterol (Neovent, Serevent Indications:
Accuhaler/Evohaler) 1. Asthma
Indications: 2. Prophylaxis of exercise-induced
1. Reversible airways obstruction in Pts requiring bronchospasm
long-term bronchodilator therapy
3. Exacerbation of reversible airways obstruction
2. Prophylaxis of exercise-induced
bronchospasm 4. Uncomplicated premature labour (between
22-37 weeks of gestation)
3. COPD
Advice: Pts must not use inhaler for the relief of
acute attacks and must not exceed prescribed
OBSTRUCTIVE AIRWAYS Tiotropium (Spiriva, Braltus)
DISEASE Indications:
1. Maintenance of COPD
Inhaled Antimuscarinics 2. Severe asthma (Spiriva)
- aclidinium bromide with formoterol (Duaklir),
glycopyrronium with indacaterol (Ultibro MHRA/CHM: with Braltus, there’s a risk of
Breezhaler), ipratropium with salbutamol inhalation of the capsule if placed in the
(Combivent), tiotropium with olodaterol (Spiolto) mouthpiece of the inhaler. Pts are at risk of
aspiration or airway obstruction. Hence, Pts
!: bladder outflow obstruction, prostatic should store caps in the bottle provided (not in
hyperplasia, angle-closure glaucoma the inhaler) and always check the mouthpiece
before inhaling
SEs: arrhythmias, cough, dry mouth, epistaxis,
constipation, palpitations, glaucoma, urinary Umeclidinium (Incruse Ellipta)
disorders, blurred vision
Indication: maintenance of COPD
Aclidinium bromide (Eklira) Dose (powder inhalation): 55mcg OD
Indication: maintenance of COPD Umeclidinium with vilanterol (Anoro Ellipta)
Dose (powder inhalation): 375mcg BD Indication: maintenance of COPD
Glycopyrronium bromide (Seebri Breezhaler) Dose (powder inhalation): 1 inhalation OD
Indication: maintenance of COPD X: severe pre-eclampsia
Dose (powder inhalation): 1 cap (55mcg) OD !: hypokalaemia may be enhanced with
concomitant use of theophylline, corticosteroids,
SEs: increased risk of infection, insomnia, diuretics and by hypoxia
hyperglycaemia, throat irritation
M: plasma-potassium concentration and monitor
Ipratropium bromide (Atrovent, Inhalvent) blood glucose in diabetics due to risk of
hyperglycaemia and ketoacidosis
Indications:
1. Reversible airways obstruction Selective Beta-2 Adrenoceptor
2. Airways obstruction in COPD
Agonists
3. Acute bronchospasm
4. Severe or life-threatening asthma X: severe pre-eclampsia
PK: maximal effect occurs 30-60mins post use; !: diabetes (risk of hyperglycaemia and
duration of action is 3-6hrs and bronchodilation ketoacidosis), hypertension, hyperthyroidism,
can be maintained with treatment 3 times daily hypokalaemia, QT-interval prolongation
!: angle-closure glaucoma reported with nebulised SEs: hyperglycaemia, palpitations, tremor
use, especially when given with nebulised
salbutamol M: in severe asthma, monitor plasma-K conc. In
diabetics, monitor blood glucose levels
SEs: corneal oedema
Advice: when used by inhalation, the dose,
X: H/O to atropine or its derivatives frequency and max number of inhalations in 24hrs
Advice: risk of dizziness and vision disorders should be stated explicitly.
hence take caution with skilled tasks
, Chapter 3 – Respiratory System
Selective Beta-2 Adrenoceptor dose. Any deterioration in symptoms following
Agonists (Long-Acting) initiation must be reported
- bambuterol (Bambec), indacaterol (Onbrez Selective Beta-2 Adrenoceptor
Breezhaler), olodaterol (Striverdi Respimat) Agonists (Short-Acting)
CHM: for chronic asthma, long-acting beta-2 M: in labour, monitor BP, pulse rate (should be
agonists should be added only if regular use of <120bpm), ECG (discontinue if signs of myocardial
standard ICS has failed to control symptoms, be ischaemia develop), blood glucose and lactate
introduced at a low dose, not be initiated in Pts concentrations, fluid status (discontinue if
with rapidly deteriorating asthma, not be used for pulmonary oedema occurs and initiate diuretics)
the relief of exercise-induced asthma symptoms
Advice: for inhalation by aerosol or dry powder,
unless regular ICS are also used and be
do not exceed the prescribed dose. If a previously
discontinued in the absence of benefit.
effective dose fails to provide at least 3hrs of
PK: duration of action is approx. 12hrs relief, obtain advice. For inhalation by nebuliser,
the dose given is much higher than given by an
Formoterol fumarate (Easyhaler, Oxis inhaler hence it’s dangerous to exceed the
Turbohaler, Atimos Modulite) prescribed dose.
Indications: PK: duration of action is 3 to 5 hours
1. Reversible airways obstruction
Salbutamol (Easyhaler, Ventolin
2. Chronic asthma in Pts who regularly use an Accuhaler/Evohaler, Salamol)
inhaled corticosteroid
Indications:
3. COPD 1. Asthma
4. Relief of bronchospasm 2. Prophylaxis of allergen- or exercise-induced
bronchospasm
5. Prophylaxis of exercise-inhaled bronchospasm
3. Uncomplicated premature labour (between
Advice: Pts must not exceed prescribed dose and 22-37 weeks of gestation)
report any deterioration in symptoms following
initiation of Tx Terbutaline (Bricanyl)
Salmeterol (Neovent, Serevent Indications:
Accuhaler/Evohaler) 1. Asthma
Indications: 2. Prophylaxis of exercise-induced
1. Reversible airways obstruction in Pts requiring bronchospasm
long-term bronchodilator therapy
3. Exacerbation of reversible airways obstruction
2. Prophylaxis of exercise-induced
bronchospasm 4. Uncomplicated premature labour (between
22-37 weeks of gestation)
3. COPD
Advice: Pts must not use inhaler for the relief of
acute attacks and must not exceed prescribed
