netFormulary NHS
Pan Mersey
Area Prescribing Committee
 Search
 Formulary Chapter 3: Respiratory system - Full Chapter
Notes:

Review date: March 2022

Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.

Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol View childrens BNF) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Chapter Links...
 Details...
03.01  Expand sub section  Bronchodilators
03.01  Expand sub section  Croup
 note 

Bronchiolitis or croup

Current guidance states antibiotics not indicated for croup.

Symptomatic treatment only is recommended.

BNF 3.1 states for croup medical emergencies in community a single dose of dexamethasone oral solution is of benefit.

Prednisolone may also be used as dexamethasone solution may not be available in all community pharmacies

See Formulary Chapter 6 for preparations.

03.01.01  Expand sub section  Adrenoceptor agonists
03.01.01.01  Expand sub section  Selective Beta2 agonists
Bambuterol
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 10 mg

Paediatrics: no BNFc entry - seek specialist advice

 
   
Terbutaline
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 5 mg

 

Amber Initiated Paediatrics

 
   
03.01.01.01  Expand sub section  Short-acting beta2 agonists to top
 note 

RightBreathe Short-acting beta2 agonsists - Inhaler Prescribing Information (with images)

Salbutamol aerosol inhalation
View adult BNF View SPC online View childrens BNF
First Choice
Green

Metered dose inhaler

100 micrograms/metered inhalation

PREFERRED CHOICE IN ASTHMA AND COPD

 
Salbutamol dry powder for inhalation
View adult BNF View SPC online View childrens BNF
First Choice
Green
Device Dry powder inhaler
Easyhaler PREFERRED CHOICE IN ASHTMA AND COPD
100 micrograms/metered inhalation
200 micrograms/metered inhalation
Ventolin Accuhaler 200 micrograms/blister
 
Terbutaline sulphate dry powder for inhalation (Bricanyl Turbohaler® ®)
View adult BNF View SPC online View childrens BNF
First Choice
Green

Dry powder inhaler

PREFERRED choice in ASTHMA and COPD

500 micrograms/metered inhalation

 

 
Salbutamol aerosol inhalation breath actuated
View adult BNF View SPC online View childrens BNF
Formulary
Green

Breath actuated inhaler

100 micrograms/metered inhalation

 
   
Salbutamol nebuliser solution
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

2.5 mg/2.5 mL (1 mg/mL)

5 mg/2.5 mL (2 mg/mL)

Green Acute administration in primary care

 
   
Terbutaline nebuliser solution
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended
5 mg/2 mL (2.5 mg/mL)

Green Acute administration in primary care
 
   
Salbutamol oral
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Oral syrup 2mg in 5ml (sugar free)

Step 4 asthma

Amber Initiated Paediatrics

 
   
Salbutamol injection
View adult BNF View SPC online View childrens BNF
Formulary
Red

Injection 500 micrograms/mL

Solution for intravenous infusion 1 mg/mL

 
   
Terbutaline injection
View adult BNF View SPC online View childrens BNF
Formulary
Red
Injection 500 micrograms/mL 
   
03.01.01.01  Expand sub section  Long-acting beta2 agonists
 note 

The Commission on Human Medicines (CHM) has advised that for the management of chronic asthma, long acting beta2 agonists should ONLY be added if regular use of standard-dose inhaled corticosteroids has failed to control asthma adequately and should be started at a low dose with the effect properly monitored before considering dose increase. They should NOT be used for immediate relief of acute asthma attacks, for rapidly deteriorating asthma, or for exercise induced asthma without a concomitant inhaled corticosteroid e.g. SMART dosing. Patients should be advised to report signs of symptom deterioration. Long acting beta2 agonists should be discontinued if there is no benefit to the patient and should be reviewed as clinically appropriate with a view to stepping down.

RightBreathe Long-acting beta2 agonist - Inhaler Prescribing Information (with images)

Formoterol fumarate metered dose inhaler (Atimos Modulite® )
View adult BNF View SPC online View childrens BNF
First Choice
Green

Metered dose inhaler

12 micrograms/metered inhalation

PREFERRED CHOICE IN COPD

 
Formoterol fumarate dry powder for inhalation
View adult BNF View SPC online View childrens BNF
Formulary
Green
Device Dry powder inhaler
Easyhaler 12 micrograms/metered inhalation
Oxis Turbohaler 6 micrograms/metered inhalation
12 micrograms/metered inhalation

 

 
   
Indacaterol inhalation powder (Onbrez Breezhaler®)
View adult BNF View SPC online
Formulary
Green

Dry powder inhaler

PAEDIATRICS: no BNFc entry - seek specialist advice

150 micrograms/capsule
300 micrograms/capsule

 
   
Salmeterol aerosol inhalation
View adult BNF View SPC online View childrens BNF
Formulary
Green

Metered dose inhaler

25 micrograms/metered inhalation

 
   
Salmeterol dry powder for inhalation (Serevent Accuhaler®)
View adult BNF View SPC online View childrens BNF
Formulary
Green

Dry powder inhaler

50 micrograms/blister

 
   
Olodaterol solution for inhalation (Striverdi Respimat®▼)
View adult BNF View SPC online
Formulary
Grey

Solution for inhalation cartridge with device

Not recommended for use at this time

2.5 micrograms per dose

 
   
03.01.01.02  Expand sub section  Other adrenoceptor agonists
03.01.02  Expand sub section  Antimuscarinic bronchodilators
 note 

RightBreathe Short-acting muscarinic antagonist - Inhaler Prescribing Information (with images)

RightBreathe Long-acting muscarinic antagonist - Inhaler Prescribing Information (with images)

RightBreathe Long-acting beta2 agonist plus long-acting muscarinic antagonist - Inhaler Prescribing Information (with images)

Tiotropium inhalation powder
(For COPD)
View adult BNF View SPC online
First Choice
Green

Dry power inhaler

10 micrograms per capsule (Braltus Zonda® Hard capsule and Zonda® device)

PREFERRED CHOICE IN COPD
Prescribe by brand name.
Dry powder inhaler unlicensed in asthma.
Paediatrics: no BNFc entry - seek specialist advice

 
Tiotropium solution for inhalation
(For COPD and asthma)
View adult BNF View SPC online View childrens BNF
First Choice
Green

Solution for inhalation

2.5 micrograms/metered inhalation (Respimat®)

PREFERRED CHOICE IN COPD
For use in Step 4 Asthma
Grey Paediatrics: no BNFc entry - seek specialist advice

 
Aclidinium bromide inhalation powder (Eklira Genuair®)
View adult BNF View SPC online
First Choice
Green

Dry powder inhaler

400 micrograms/metered inhalation

PREFERRED CHOICE IN COPD

Paediatrics: no BNFc entry - seek specialist advice

 
Glycopyrronium inhalation powder (Seebri Beezhaler®)
View adult BNF View SPC online
First Choice
Green

Dry powder inhaler
Hard capsule, for use with Seebri Beezhaler® device

50 micrograms per capsule

PREFERRED CHOICE IN COPD

Paediatrics: no BNFc entry - seek specialist advice

 
Tiotropium with Olodaterol  (Spiolto Respimat®)
View adult BNF View SPC online
First Choice
Green

Inhalation solution (Respimat®)

Tiotropium 2.5microgram / Olodaterol 2.5microgram per dose

PREFERRED CHOICE IN COPD

Paediatrics: no BNFc entry - seek specialist advice

 
Aclidinium with formoterol (Duaklir Genuair®)
View adult BNF View SPC online
First Choice
Green

Dry powder inhaler

Aclidinium 340 micrograms with formoterol 12 micrograms per inhalation

PREFERRED CHOICE IN COPD

Paediatrics: no BNFc entry - seek specialist advice

 
Glycopyrronium with indacaterol inhaler (Ultibro Breezhaler®)
View adult BNF View SPC online
First Choice
Green

Capsules for inhalation via Breezhaler inhaler device

Indacaterol 85 micrograms with glycopyrronium 43 micrograms per inhalation

PREFERRED CHOICE IN COPD

Paediatrics: no BNFc entry - seek specialist advice

 
Umeclidinium bromide inhalation powder (Incruse Ellipta®)
View adult BNF View SPC online
First Choice
Green

Dry powder inhaler

55 micrograms per inhalation

Paediatrics: no BNFc entry - seek specialist advice

 
Umeclidinium with vilanterol (Anoro Ellipta®)
View adult BNF View SPC online
First Choice
Green

Dry powder inhaler

Umeclidinium 55 micrograms with vilanterol 22 micrograms per inhalation

Paediatrics: no BNFc entry - seek specialist advice

 
Ipratropium bromide aerosol inhalation
View adult BNF View SPC online View childrens BNF
Formulary
Green

Metered dose inhaler

20 micrograms/metered inhalation

Short-acting muscarinic antagonist

 
   
Ipratropium bromide nebuliser solution
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

250 micrograms/mL

500 micrograms/2 mL (250 micrograms/mL)

Short-acting muscarinic antagonist

 
   
03.01.03  Expand sub section  Theophylline
 note 

Note: Plasma-theophylline concentration for satisfactory bronchodilation is 10 - 20 mg/litre (4-6 hours after dose and at least 5 days after starting treatment). However, lower plasma theophylline concentrations may be effective.  There is a narrow margin between therapeutic and toxic doses.  Due to the metabolism of theophylline it is important to consult product literature for any potential interactions with concomittant medication.

Due to variation in rates of absorption, modified release preparations of theophylline and aminophylline must be prescribed by brand.

Uniphyllin Continus®
View adult BNF View SPC online View childrens BNF
First Choice
Green

Theophylline MR; Tablets m/r 200 mg, 300 mg, 400 mg

COPD

Amber Recommended  Asthma

Amber Initiated Paediatrics

 
Slo-Phyllin®
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Theophylline capsules m/r 60 mg, 125 mg, 250 mg

COPD

Amber Recommended  Asthma

Amber Initiated Paediatrics

 
   
Nuelin SA®
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Theophylline tablets m/r 175 mg, 250 mg

COPD

Amber Recommended  Asthma

Amber Initiated Paediatrics

 
   
Phyllocontin Continus®
View adult BNF View SPC online View childrens BNF
Formulary
Green

Aminophylline tablets m/r 225 mg

COPD

Amber Recommended  Asthma

Amber Initiated Paediatrics

 
   
Phyllocontin Continus Forte®
View adult BNF View SPC online View childrens BNF
Formulary
Green

Aminophylline tablets m/r 350 mg
(these are for smokers and other patients with shorter theophylline half life)

COPD

Amber Recommended  Asthma

Amber Initiated Paediatrics

 
   
Aminophylline injection
View adult BNF View SPC online View childrens BNF
Formulary
Red
Injection 25 mg/mL, 10-mL amp  
   
Theophylline
View adult BNF View childrens BNF
Unlicensed Drug Unlicensed
Amber Initiated
Oral liquid 50mg/5ml (unlicensed Special)

Paediatrics 
   
03.01.04  Expand sub section  Compound bronchodilator preparations to top
03.01.05  Expand sub section  Peak flow meters, inhaler devices and nebulisers
Inspiratory muscle training devices
Formulary
Amber Initiated

POWERbreathe® Medic

Threshold IMT®

Ultrabreathe®

Not recommended for routine use, but inspiratory muscle training may be considered in those with COPD, non- CF bronchiectasis and upper spinal cord injuries.

 
   
03.01.05  Expand sub section  Peak flow meters
 note 
Standard-range peak flow meters are suitable for both adults and children.
Low-range peak flow meters are appropriate for severely restricted airflow in adults and children.
Standard Range Peak Flow Meter Usual range 50 – 800 litres/minute
Low Range Peak Flow Meter Usual range 40 – 400 litres/minute
03.01.05  Expand sub section  Drug delivery devices
 note 

Spacer devices

Spacer devices can be used with MDI inhalers for patients to improve lung deposition of drug.

The size of the spacer is important, the larger spacers with a one-way valve (Volumatic®) are the most effective.

Paediatrics: In practice, local experience supports the use of Volumatic® spacer in children.

RightBreathe Spacers - Prescribing Information (with images)

Large volume device (Volumatic®)
View adult BNF View SPC online View childrens BNF
First Choice
Green

Spacer inhaler

First choice in paediatrics with paediatric mask

For use with Clenil Modulite®, Flixotide®, Seretide®, Serevent® and Ventolin® metered dose inhalers

 
Inhalation aid (Haleraid®)
View adult BNF View SPC online View childrens BNF
Formulary
Green

Haleraid® -120 For 120 dose inhalers
Haleraid® -200 For 200 dose inhalers

Device to place over pressurised (aerosol) inhalers to aid when strength in hands is impaired (e.g. in arthritis).

For use with Flixotide®, Seretide®, Serevent® and Ventolin® inhalers.

Please note these devices are not allowable on NHS prescriptions, but can be purchased by patients.

 
   
Medium-volume device (Space Chamber Plus ®)
View adult BNF View childrens BNF
Formulary
Green

Spacer device

With or without small, medium or large mask

For use with all pressurised (aerosol) inhalers

 
   
Small volume device (Space Chamber Plus Compact® )
View adult BNF View childrens BNF
Formulary
Green

Spacer device

With or without small, medium or large mask.

For use with all pressurised (aerosol) inhalers

 
   
03.01.05  Expand sub section  Nebulisers
03.01.05  Expand sub section  Nebuliser Diluent to top
Sodium Chloride
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended
Nebuliser solution, 0.9%, 2.5 mL

Green For acute administration in primary care 
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection.  Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

netFormulary