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RESPIRATORY

CONDITIONS

RESPIRATORY STRUCTURES

& FUNCTIONS

UPPER

Respiratory Tract

LOWER

Respiratory Tract

Mouth

Nose

Pharynx

(Larynx)

Larynx

Trachea

Bronchi/Bronchioles

Alveoli/Lungs

THE RESPIRATORY TRACT

The Sinuses

Maxillary Frontal

Ethmoid Sphenoid

UPPER RESPIRATORY TRACT

Inspiration

Normal

Expiration

Forced

Normal

Forced

Only diaphragm

contracts

Abdominal/internal

intercostals contract

External intercostals

contract

Diaphragm

relaxes

RESPIRATION

MECHANICS OF RESPIRATION

Tidal Volume

Inspiratory

Reserve

Volume

Expiratory

Reserve

Volume

Residual volume

Vital Capacity

RESPIRATION / LUNG CAPACITIES

(FEV1)

ALVEOLUS

Alveolus

Capillary

PO2 = 105

PCO2 = 40

GAS EXCHANGE (PO2/PCO2)

PO2 = 40

PCO2 = 45

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RESPIRATORY

EPITHELIUM

Mucous glands

Goblet cells

Cilia

Mucus-producing cells

Mucociliary escalator (5-

10mm/minute)

MUCOUS MEMBRANE

Clearance

rate

Optimum range

Watery mucus Viscous mucus

MUCOCILIARY CLEARANCE

Mucous

Glycoprotein

Disulfide cross-bridges

Glycoprotein Matrix

MUCOUS

Mucolytic

Mucous

Glycoprotein

Disulfide cross-bridges

Glycoprotein Matrix

MUCOUS

ASTHMA

RESPIRATORY CONDITIONS

UPPER RESPIRATORY CONDITIONS

Otitis Media

Pharyngitis

Allergic Rhinitis

Laryngitis

Tonsillitis

Influenza

Sinusitis

Common Cold

LOWER RESPIRATORY CONDITIONS

Otitis Media

Coughing

Tuberculosis

Asthma CAP

Bronchi-ectasis

Pertussis

The Common Cold • Viral, airborne, contagious

• Nasal, sinuses, ears, bronchi

• Children at greater risk

• Treatments: analgesics, decongestants, antihistamines, cough remedies, rest, increased fluids

Influenza (‘Flu’) • Mutating viral attacks

• Nose, throat, lungs, malaise, dry cough

• Children, elderly

• Secondary infections (sinusitis, OM, bronchitis, CAP)

• Treatments: analgesics, decongestants, antihistamines, cough remedies, antibacterials, bed rest, increased fluids

UPPER RESPIRATORY CONDITIONS

Allergic Rhinitis / Hayfever

1 in 7 people, QoL, starts < 20 yrs

Seasonal (Pollens, spores)

Itching (throat, ears, eyes), sneezing, stuffy/runny nose

Perennial (Dust, fur, feathers, fungi)

Symptoms similar to SAR, less intense, longer-lasting

Combination

Sinusitis

Acute - purulent discharge, pain, swelling & tenderness

Chronic - mild discharge, often asymptomatic

UPPER RESPIRATORY CONDITIONS

Cough Productive (‘Wet’ [phlegm]) cough

Non-productive (‘Dry’) cough

Productive cough Viscosity of phlegm

Force of coughing

Cough therapy Treat the cause

Suppress the cough reflex

Suppress a wet cough?

UPPER RESPIRATORY CONDITIONS

Asthma (Gk: ‘panting’)

Two Types Extrinsic (‘Atopic’) – allergens (dust, stress, exertion,

weather changes)

Intrinsic (‘Non-atopic’) – no allergen (EIA)

Not COPD Emphysema, Chronic Bronchitis (AECB), Bronchiectasis

Treatment: bronchodilator

LOWER RESPIRATORY CONDITIONS

Chronic Bronchitis Emphysema

COPD

Dyspnoea after cough/phlegm

Obese

Blue face

Normal chest

Harsh breathing

Enlarged heart

Airways obstruction reversible

Normal, slightly TLC

Copious, green phlegm

Low O2, raised CO2

R heart failure common, fatal

Dyspnoea before cough/phlegm

Skinny

Pink face

Inflated chest

Quiet breath sounds

Long, thin heart

Airways blockage permanent

TLC

Moderate, white phlegm

Low O2, low CO2

R heart failure rare

LOWER RESPIRATORY CONDITIONS

Gram Positive Streptococcus pneumoniae

Staphylococcus aureus

Gram Negative Moraxella catarrhalis

Haemophilus influenzae

Atypical Mycoplasma pneumoniae

Mycobacterium tuberculosis

Klebsiella pneumoniae

Chlamydia pneumoniae

Antibiotics perform two

types of actions:

Bacterio-static

(inhibits growth)

Bacteri-cidal

(destroys)

Commensals Opportunistic pathogens Symbiosis

RESPIRATORY TRACT INFECTIONS

TREATMENT FOR

RESPIRATORY CONDITIONS

Treatment

for

Coughs & Colds

Antihistamines

Decongestants

Bronchodilators

Expectorants

Analgesics

Antitussives

TREATMENTS FOR COUGH/COLDS

Antihistamines

TREATMENTS FOR COUGH/COLDS

(Des)loratadine

Phenyltoloxamine

Doxylamine

Diphenhydramine

Promethazone

Chlorpheniramine

Brompheniramine

Triprolidine

Antihistamines

Histamine • Inflammatory mediator (allergen-driven)

• Sneezing, coughing, runny / blocked nose

Antihistamines - 2 classes: • Older “first generation”, “sedating” antihistamines

• Newer “second generation”, “non-sedating” antihistamines

ANTIHISTAMINES

Pharmacological management

Antihistamines

Decongestants

Intranasal cromolyn

Anticholinergics

Corticosteroids

Immunotherapy

ALLERGIC RHINITIS

A 3rd generation antihistamine – acts within 30mins

10 times more potent than loratadine in vivo

More potent antagonist at H1 receptors

Less sedation (no BBB), no cardiac AEs (QT)

Has significant anti-inflammatory effects

Has significant decongestant effects

(DES)LORATADINE

Food does not affect its absorption

No clinically relevant drug-drug interaction

No potentiation of adverse psychomotor effects of alcohol

Protects against allergen challenges for up to 24 hours

(DES)LORATADINE

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Early Phase allergic response

The primary effect is the release of histamine

Symptoms are mainly impacting the nose and eyes – running, watery

Sufferers called SNEEZERS and RUNNERS (usually Seasonal AR)

(DES)LORATADINE

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Early Phase allergic response

The primary effect is the release of histamine

Symptoms are mainly impacting the nose and eyes – running, watery

Sufferers called SNEEZERS and RUNNERS (usually Seasonal AR)

Late Phase allergic response

Immune response (white blood cells) kicks in, characterised by inflammation

Symptoms are congestion and stuffiness

Sufferers called BLOCKERS (usually Perennial AR)

(DES)LORATADINE

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Early Phase allergic response

The primary effect is the release of histamine

Symptoms are mainly impacting the nose and eyes – running, watery

Sufferers called SNEEZERS and RUNNERS (usually Seasonal AR)

Late Phase allergic response

Immune response (white blood cells) kicks in, characterised by inflammation

Symptoms are congestion and stuffiness

Sufferers called BLOCKERS (usually Perennial AR)

Desloratadine works in both Early and Late phase AR (2nd generation

antihistamines work only in the early phase)

While not as potent as intranasal steroids (INS), DES nevertheless reduces

inflammation (blocked nose, stuffiness)

Studies show that DES significantly reduces the need for INS or decongestants

(DES)LORATADINE

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Why should I use antihistamine tablets over a nasal spray?

Answer:

Although there is a place for nasal sprays in the treatment of allergic

rhinitis, you can’t use them for long periods of time as you may end up

with rebound. Nasal sprays also lead to nasal ulcerations, nose and

throat irritation, sneezing and changes in taste. Desloratadine is proven

to reduce nasal congestion and inflammation, so when using it for your

allergic rhinitis patients you do not even have to worry about using a

nasal spray or the side effects it comes with, not to mention adding to the

cost of treatment.

(DES)LORATADINE

TREATMENTS FOR COUGH/COLDS

Antitussives

Dextromethorphan

Codeine

Noscapine

Pholcodine

Coughing - protective mechanism

Type of cough determines Tx

Symptom of an underlying disorder

Cough drugs target the cough reflex

CNS-acting drugs raise cough threshold (CNS Cough Centre)

Peripherally-acting drugs decrease RT receptor sensitivity

Indirect effects

• Alter mucociliary factors

• Local analgesic or anaesthetic action on receptors

• Protecting the receptors from irritant stimuli

COUGH SUPPRESSANTS

Non-productive – often from viral infections

Treat underlying disorders (eg. asthma, chronic

bronchitis, heart failure/pulmonary congestion, lung

cancer, oesophageal reflux, post nasal drip, etc)

Provide patient relief from non-productive cough,

particularly if administered at night

COUGH SUPPRESSANTS

TREATMENTS FOR COUGH/COLDS

Decongestants

Phenylephrine

Phenylpropanolamine

L-/pseudo-Ephedrine

Reduce the volume of nasal mucosa • Contraction/shrinking of arterioles supplying the nasal

mucosa

• Opens airways = alpha-adrenergic agonists

Common decongestants: • Pseudoephedrine (new Dimetapp, Colcaps, Demazin,

Flusin, Nurofen C&F, Sinuclear, Sinumax, Degoran)

• Phenylpropanolamine / PPA (old Dimetapp, old Degoran, Colcaps caps, Rinex, Sinuclear, Sinustat, Sinutab selected)

• Phenylephrine (Colcaps, Corenza, Demazin, Grippon, Rinex)

Available orally (tabs, caps, syrup) & topically (gels, sprays, drops)

DECONGESTANTS

TREATMENTS FOR COUGH/COLDS

Bronchodilators

Aminophylline

Orciprenaline

Terbutaline

Expectorants

Ammonium Chloride

Guaiphenesin

Mucolytics

Carbocysteine

Bromhexine

Expectorants

TREATMENTS FOR COUGH/COLDS

Expectorants

Ammonium Chloride

Guaiphenesin

Mucolytics

Carbocysteine

Bromhexine

Expectorants

TREATMENTS FOR COUGH/COLDS

Mucolytic

TREATMENTS FOR COUGH/COLDS

Analgesics

Aspirin

Paracetamol

Acetominophen

Phenacetin

Codeine

NSAID’s (non-steroidal anti-inflammatory drug):

• Ibuprofen (Advil, Nurofen), aspirin (Anadin, GrandPa,

Disprin), & naproxen (Alleve)

• Effective in relieving inflammation, pain & fever

Paracetamol:

• Panado, Calpol, Paramed

• Effective in relieving pain & fever

• Caution with unintentional overdose, as many cold

preparations already contain Paracetamol (Sinumax,

Colcaps, Sinuclear)

• Particular caution with children

ANALGESICS

Antihistamines Decongestants

Bronchodilators Expectorants Antitussives

Analgesics Mucolytics

Phenyltoloxamine

Doxylamine

Pseudoephedrine

L-ephedrine

Paracetamol

Phenacetin

Aspirin

Codeine

Acetaminophen

Carbocysteine

Orciprenaline Guaifenesin Codeine

Aminophylline Dextromethorphan

Phenylpropanolamine

Pholcodine

Noscapine

Ammonium chloride

Diphenhydramine

Promethazone

Triprolidine

Terbutaline

Phenylephrine

Bromhexine

TREATMENTS FOR COUGH/COLDS

This presentation contains forward-looking statements about the company’s operations

and financial conditions. They are based on Litha Healthcare Group Limited’s best

estimates and information at the time of writing. They are nonetheless subject to

significant uncertainties and contingencies many of which are beyond the control of the

company. Unanticipated events will occur and actual future events may differ materially

from current expectations due to new business opportunities, changes in priorities by the

company as well as other factors. Any of these factors may materially affect the

company’s future business activities and its ongoing financial results.

DISCLAIMER

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