Section 3: Respiratory System

Section Description

Misc 1

Management of chronic asthma in adults and children

Misc 2

Chronic Obstructive Pulmonary Disease (C.O.P.D.)

BNF 3.1.1.1

Selective beta2 agonists

BNF 3.1.1.2

Other adrenoceptor agonists

BNF 3.1.2

Antimuscarinic bronchodilators

BNF 3.1.3

Theophylline

BNF 3.1.4

Compound bronchodilator preparations

BNF 3.1.5

Peak flow meters, inhaler devices & nebulisers

BNF 3.2

Corticosteroids

BNF 3.3.1

Cromoglicate and related therapy

BNF 3.3.2

Leukotriene receptor antagonists

BNF 3.3.3

Phosphodiesterase type-4 inhibitors

BNF 3.4.1

Antihistamines

BNF 3.4.2

Allergen immunotherapy

BNF 3.4.3

Allergic emergencies

BNF 3.5.1

Respiratory stimulants

BNF 3.5.2

Pulmonary surfactants

BNF 3.6

Oxygen

BNF 3.7

Mucolytics

BNF 3.8

Aromatic inhalations

BNF 3.9.1

Cough suppressants

BNF 3.9.2

Expectorant and demulcent cough preparations

BNF 3.10

Systemic nasal decongestants

BNF 3.11

Antifibrotics

BNF 3.13 

Nebulised antibiotics for cystic fibrosis 

Management of chronic asthma in adults and children

Advice on the management of chronic asthma is based on the recommendations of the British Thoracic Society and the Scottish Intercollegiate Guidelines Network SIGN Guideline

Asthma control assessment tool for patients - Asthma Control Test

Administration of drugs for asthma

Asthma – inhaler devices for older children. NICE TA38

Asthma – inhalers for children under five. NICE TA10

Breath-actuated inhalers are suitable for use in children over 7 years and dry-powder inhalers may be useful in children over 5 years who are unwilling or unable to use a pressurised metered dose inhaler with a spacer device (BNF for Children 2005; 168)

Number of days supply in one inhaler

Dose per inhaler

2 doses/puffs
twice a day

2 doses/puffs
three times a day

2 doses/puffs
four times a day

200

50

33

25

120

30

20

15

60

15

10

7.5

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (C.O.P.D.)

Chronic obstructive pulmonary disease. NICE CG101

Wolverhampton CCG COPD Guidelines

Wolverhampton Chronic Obstructive Pulmonary Disease Treatment Guidelines

BNF 3.1.1.1 Selective beta2 agonists

Relief of Acute Attacks - short-acting beta2 agonists (SABA)

Salbutamol

Prescribe inhaler by brand name

CFC-free aerosol inhaler

CFC-free aerosol inhaler e.g. Ventolin Evohaler®

CFC-free breath actuated aerosol inhaler

Breath actuated dry powder inhaler 95mcg - Asmasal Clickhaler®

Breath actuated dry powder inhaler - Ventolin Accuhaler®

Nebuliser solution

ORAL: sugar-free liquid 2mg in 5ml, and tablets

Salbutamol injection - Specialist/Hospital prescribing only

Terbutaline

 

Breath actuated dry powder inhaler 500mcg per actuation - prescribed by brand name

Nebuliser solution

Terbutaline injection - Specialist/hospital prescribing only

 Longer Acting Bronchodilator Therapy (LABA)

Salmeterol inhaler

Prescribe by brand name. When prescribed for asthma, check patient is using an inhaled corticosteroid

Formoterol inhaler

Prescribe by brand name. When prescribed for asthma, check paient is using an inhaled corticosteroid

Indacaterol inhaler

Prescribe by brand name. When prescribed for asthma, check patient is using an inhaled corticosteroid

For LABA combined with inhaled corticosteroid - see BNF 3.2

BNF 3.1.1.2  Other adrenoceptor agonists

Products from this section are not recommended for prescribing.

BNF 3.1.2 Antimuscarinic bronchodilators

Short-acting antimuscarinic bronchodilator (SAMA)

Ipratropium bromide

CFC-free aerosol

Nebuliser solution 500mcg in 2ml

Long-acting antimuscarinic bronchodilator (LAMA)
Aclidinium bromide inhaler

Breath actuated dry powder inhaler
Twice daily dosing (COPD)

Eklira Genuair®
Glycopyrronium bromide inhaler Breath actuated dry powder capsules
Once daily dosing (COPD)
Seebri Breezhaler®

Tiotropium bromide inhaler

Breath actuated dry powder capsules
Once daily dosing (COPD)

Braltus Zonda®

Inhalation solution
Two puffs once daily (asthma and COPD)
Spiriva Respimat®
Umeclidinium bromide inhaler

Breath actuated dry powder inhaler
Once daily dosing (COPD)

Incruse Ellipta®

BNF 3.1.3 Theophylline

Aminophylline

Oral. Prescribe as branded product

Injection: Specialist/Hospital prescribing only

Theophylline

Prescribe as branded product e.g. Uniphyllin®
Ensure smokers know that smoking affects drug levels & theophylline dosage adjustment needed during smoking cessation.

Drug level monitoring
Take blood samples 24-48 hours after starting treatment or changing dose to allow attainment of steady state. Steady state may not be reached for 5-6 days in neonates.
Sampling time varies depending on the formulation:

  • IV infusion – sample at any time
  • Oral liquid and other rapidly absorbed formulations – sample just before dose (trough level) and 2-3 hours after dose (peak level)
  • Sustained or modified release formulations – sample just before dose (trough level) or 5-6 hours after dose (peak level)

It is advisable to measure both peak and trough levels in patients who metabolise theophylline rapidly e.g. smokers and children, because they may exhibit significant variations in levels even on sustained-release formulations.

Ongoing monitoring

See "Suggestions for Drug Monitoring in Adults in Primary Care" October 2017 page 83

BNF 3.1.4  Compound bronchodilator preparations

LABA+LAMA combined inhalers

Suitable for patients who continue to be breathless on LABA or LAMA but have less than one exacerbation per year. 

Aclidinium bromide + formoterol inhaler

Duaklir Genuair®

Twice daily (COPD) 

Glycopyrromium bromide + indacaterol inhaler Ultibro Breezhaler® Once daily (COPD)
Tiotropium bromide + olodaterol inhaler Spiolto Respimat® Once daily (COPD)
Umeclidinium bromide + vilanterol inhaler  Anoro Ellipta® Once daily (COPD)
With Inhaled CORTICOSTEROID
Fluticasone + umeclidinium + vilanterol Trelegy® Ellipta Once daily (COPD)
Beclometasone + formoterol + glycopyrronium Trimbow® Twice daily (COPD)

BNF 3.1.5 Peak flow meters, inhaler devices & nebulisers

Peak Flow Meters

Replacement mouthpieces (suitable for both adults and children) can be prescribed. State brand (e.g. Vitalograph®) because products are not interchangeable.

Spacer Devices

Able Spacer®

AeroChamber Plus®

Flo-Tone MDI®

Volumatic®

Inhaler devices for children aged under 5 with chronic asthma NICE TA10

Inhaler devices for children aged 5 – 15 years with chronic asthma NICE TA38

Nebulisers
Nebulisers and compressors are not available on the NHS in England or Wales.
Before prescribing a nebuliser, a home trial should preferably be undertaken to monitor response for up to 2 weeks on standard treatment and up to 2 weeks on nebulised treatment. If prescribed, patients must:

Nebuliser diluent

Sodium chloride 0.9% nebuliser solution

BNF 3.2 Corticosteroids

NICE Guidance - Asthma (in adults) - corticosteroids NICE TA138

NICE Guidance - Asthma (in children) - corticosteroids NICE TA131

Steroid card advice

Beclometasone

 

 

Beclometasone CFC-free inhalers are NOT interchangeable - prescribe by brand name

CFC-free aerosol inhaler - Clenil®

CFC-free aerosol inhaler -Qvar® NOT interchangeable with other beclometasone inhalers

Breath actuated dry powder inhaler

prescribe by brand name

Breath actuated -QVAR® Easi-breathe

When transferring stable patients: QVAR® 100mcg is equivalent to 200 - 250mcg beclometasone, 200 - 250mcg budesonide or 100mcg fluticasone

Budesonide

CFC-free aerosol inhaler prescribed by brand name

Breath actuated dry powder inhaler prescribed by brand name

Fluticasone

CFC-free aerosol inhaler

 

Breath actuated dry powder inhaler

e.g. Accuhaler


Combined inhalers


For asthma, separate inhalers allow more suitable dose tailoring, but combined inhalers may aid compliance and may be appropriate for patients well controlled on individual drugs. Combined inhalers attract only one prescription charge – an advantage for patients who pay for their medicines

MART regimen (Maintenance And Reliever Therapy—a combination of an inhaled corticosteroid and a fast-acting LABA such as formoterol in a single inhaler), with a low dose of inhaled corticosteroid as maintenance.  

Beclometasone & formoterol  Budesonide & formoterol Fluticasone & formoterol  Fluticasone & salmeterol  Fluticasone & vilanterol

Fostair® 100/6 inhaler/NEXThaler for asthma & COPD. Licensed for MART regimen 

Symbicort® 100/6 turbohaler for asthma. Licensed for MART regimen

Flutiform® 50mcg/5mcg inhaler for asthma

Seretide® 50 Evohaler for asthma

Seretide® 100 Accuhaler for asthma

Relvar® 92/22 for asthma and COPD

Fostair® 200/6 inhaler for asthma

Fostair® NEXThaler 200/6 for asthma  

Symbicort® 200/6 turbohaler for asthma & COPD. Licensed for MART regimen

Flutiform® 125mcg/5mcg inhaler for asthma

Seretide® 125 Evohaler for asthma

Seretide® 250 Accuhaler for asthma

Relvar® 184/22 for asthma
See note below regarding relative doses 

Symbicort® 400/12 turbohaler for asthma & COPD

Flutiform® 250mcg/10mcg inhaler for asthma

Seretide® 250 Evohaler for asthma

Seretide® 500 Accuhaler for asthma & COPD

 

NOTE: The particles of beclometasone in Fostair® are extra fine and are more potent than in standard formulations of beclometasone; 100mcg of extra fine beclometasone in Fostair® are equivalent to 250mcg of standard beclometasone. Budesonide doses are equivalent to standard beclometasone. 100mcg fluticasone is equivalent to 200mcg standard beclometasone.

 BNF 3.3.1 Cromoglicate and related therapy

These drugs may be of benefit in exercise-induced asthma

Sodium cromoglicate pressurised inhalation

BNF 3.3.2 Leukotriene receptor antagonists

The Committee on Safety of Medicines has advised that:

Montelukast oral

 

Review use after 4 weeks – only continue if benefit demonstrated.
Chewable tablets contain aspartame: avoid in phenylketonuria.

 

BNF 3.3.3 Phosphodiesterase type-4 inhibitors

Roflumilast oral

 

Initiated by Specialist in respiratory medicine

Roflumilast for treating chronic obstructive pulmonary disease NICE TA461 

BNF 3.4.1 Antihistamines

Non-Sedating Antihistamines

Once Daily Preparations

First choice:
Loratadine oral

 

10mg

“Non-sedating” antihistamines may occasionally cause sedation. Loratadine and fexofenadine have a lower incidence of sedation compared to cetirizine. [BMJ 2000; 320: 1184-1187]
Fexofenadine is not routinely stocked by the hospital. 

Second choice:
Cetirizine oral

Fexofenadine oral

10mg

 

120mg (allergic rhinitis)
180mg (urticaria)

Sedating Antihistamines

Chlorphenamine oral and injection

Least sedating of older type of antihistamine.

Hydroxyzine oral

Hydroxyzine has been included for treatment of pruritus and the short-term management of anxiety.
Hydroxyzine (Atarax, Ucerax): risk of QT interval prolongation and Torsade de Pointes  

Promethazine HCl oral

Promethazine HCl has been included for the emergency treatment of anaphylactic reactions. Not recommended for use in children under 2 years of age.

Alimemazine oral

For specialist/hospital initiation then suitable for prescribing in primary care. Alimemazine (trimeprazine tartrate) has been included for treatment of urticaria and pruritus.

Kenalog® injection is no longer advised for the prevention/treatment of hay fever

BNF 3.4.2 Allergen immunotherapy

Bee and wasp allergen extract (Pharmalgen®)

Specialist Centre Only - see NICE TA246

Mepolizumab This is a NHS England Specialised Commissioning drug for asthma. Mepolizumab for treating severe refractory eosinophilic asthma NICE TA431  

Omalizumab

Hospital/specialist prescribing only

Omalizumab for treating severe persistent allergic asthma NICE TA278, replacing technology appraisal guidance 133 and 201  

Omalizumab for previously treated chronic spontaneous urticaria NICE TA339 

Reslizumab  Hospital/specialist prescribing only Reslizumab for treating severe eosinophilic asthma NICE TA479  

BNF 3.4.3 Allergic emergencies

Adrenaline (epinephrine) injection

Please remember these injectors may be short-dated and cost more than £20 each. Emerade® is the preferred brand for use in Primary Care. BNF advises brand prescribing to ensure that patients receive the auto-injector device that they have been trained to use.

Recommended that 2 injectors prescribed

 

Adrenaline / chlorphenamine / corticosteroids used according to local guidelines

Resuscitation Council (UK) guidance

Anaphylaxis: assessment and referral after emergency treatment NICE CG134 

Dose of intramuscular injection of adrenaline (epinephrine) for anaphylactic shock

Age

Dose

Volume of adrenaline
1 in 1000 (1 mg/mL)

Child under 6 years

150 micrograms

0.15 mL

Child 6–12 years

300 micrograms

0.3 mL

Adult and adolescent *

500 micrograms

0.5 mL

* 300 micrograms (0.3ml) if adolescent is small or prepubertal.

These doses may be repeated several times if necessary at 5-minute intervals according to blood pressure, pulse and respiratory function. Subcutaneous injection not generally recommended. Use suitable syringe for measuring small volume.

Acute Attacks of Hereditary Angioedema

C1-esterase inhibitor C1-inhibitor. Hospital only (Available from Blood Bank not Pharmacy)

Icatibant

Hospital only - NHSE commissioned

 BNF 3.5.1 Respiratory stimulants

Doxapram injection - Hospital prescribing only

BNF 3.5.2 Pulmonary surfactants

Poractant Alfa endotracheopulmonary instillation suspension - Hospital prescribing only

BNF 3.6 Oxygen

Wolverhampton Home Oxygen Assessment and Review from 1st October 2012

NHS West Midlands has undertaken a procurement exercise for Home Oxygen Services. Whilst the Provider continues to be Air Products, there have been some changes to the contract for Home Oxygen Services.

The overarching principle is that the Home Oxygen Assessment and Review Service (HOS-AR) is the most appropriate mechanism for the provision of home oxygen. If you believe your patient would benefit from oxygen therapy please refer to the HOS AR using the referral form.

The new contract for Home Oxygen Services goes live from 1st October 2012. Education sessions have been delivered through Wolverhampton Team W Programme and the presentation slides can be found here.  

Key Contacts: Internal External
Wolverhampton Home Oxygen Assessment and Review Service

Ext: 5061, Fax: 5737

01902 695061 or email

PCT Patient Registration Fax: 01902 444877 Fax: 01902 444877
Air Products Fax: 0800 373 580 Fax: 0800 214 709

If you have any further questions regarding Home Oxygen, please contact Wolverhampton Home Oxygen Assessment and Review Service.

BNF 3.7 Mucolytics

Regular use of mucolytics may benefit patients with chronic obstructive pulmonary disease who suffer particularly from troublesome exacerbations.

Carbocisteine oral

For patients with swallowing difficulties please prescribe sachets in preference to the oral solution as it is more cost effective.
Review on-going need/benefit and stop if ineffective after 4-6 weeks of treatment. 

Dornase alfa nebuliser solution

This is a NHSE England Commissioned Drug for Cystic Fibrosis. Specialist/Hospital Prescribing Only 

Mannitol dry powder for inhalation

This is a NHSE England Commissioned Drug for Cystic Fibrosis. Specialist/Hospital Prescribing Only
Prescribed in accordance with NICE TA266

BNF 3.8 Aromatic inhalations

Menthol and Eucalyptus Inhalation

BNF 3.9.1 Cough suppressants

Pholcodine 5mg/5ml sugar-free linctus

Pholcodine 2mg/5ml sugar-free linctus

BNF 3.9.2 Expectorant and demulcent cough preparations

Simple Linctus  & Simple linctus (sugar free)

It is cheaper to prescribe sugar-free linctus

Simple Linctus Paediatric (sugar free)

 

BNF 3.10 Systemic nasal decongestants

Pseudoephedrine hydrochloride oral

Caution in hypertension, diabetes, hyperthyroidism, ischaemic heart disease. Contra-indicated in patients taking monoamine oxidase inhibitors (BNF 4.3.2).

BNF 3.11 Antifibrotics

Pirfenidone for treating idiopathic pulmonary fibrosis, to be prescribed by specialist centres only
see NICE TA282

BNF 3.13 Nebulised antibiotics for cystic fibrosis

Amoxicillin nebulised: Hospital prescribing only

Ceftazidime nebulised: Hospital prescribing only

Colistimethate sodium (colistin sulphomethate sodium) nebulised: Commissioned by NHS England for Cystic Fibrosis only. Hospital prescribing only

Meropenem nebulised: Hospital prescribing only

Tobramycin nebulised: Commissioned by NHS England for Cystic Fibrosis only. Hospital prescribing only