Atrovent for inhalations for children and adults

Bronchitis and bronchial asthma are quite common diseases of the respiratory system, the treatment of which is rarely treated without the use of medications. One of the effective methods of treating infectious-inflammatory pathologies affecting the respiratory system is inhalation procedures that allow delivering drugs directly to the affected area (bronchi and lungs). But such treatment gives a good effect, if you choose the right medicine for a procedure, the action of which will correspond to the patient's needs. If it is a question of increased sputum excretion and bronchial obstruction, doctors often prescribe for inhalations "Atrovent" - a drug with a bronchodilator effect.

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Indications Atrovent for inhalations

So, we already understood that the drug "Atrovent" is used exclusively for inhalations. But under what diseases can this procedure be prescribed?

The drug in the form of a solution, an aerosol for inhalations in pathologies of the lower respiratory tract, capsules can be prescribed for:

• COPD. This abbreviation refers to chronic obstructive pulmonary disease, in which the flow of air through the bronchi and lungs is insufficient for full breathing.
• Especially severe form of bronchial inflammation, which occurs with obstruction (impaired patency) of the body and called obstructive bronchitis.
• Emphysema of the lungs. This pathology, in which the bronchioles reveal pathological foci of expansion.
• Spasms of bronchial tubes with various colds and infectious pathologies, covering the respiratory system, surgical manipulations, exposure to cold air or tobacco smoke.
• Bronchial asthma. The drug is used to stop attacks of the disease, which proceeds in a mild form. Possible use for moderate symptoms. Severe forms of pathology should be treated with stronger medications
• Combination of bronchial asthma with cardiovascular pathologies.
• Enhanced production of sputum to relieve wet cough and prevent bronchial obstruction due to mucus accumulating in them.
• Conducting diagnostic procedures aimed at identifying the reversibility of obstructive processes in the bronchi and lungs, which is necessary both for diagnosis and for the prediction of treatment of pathology.
• Preparation for other inhalation procedures with the use of antibiotics, mucolytics, corticosteroids. Bronchodilators, to which Androvent refers, always goes first in the list, as they prepare bronchi for the deep introduction of other medications.

Aerosol with a nasal nozzle is used mainly for the treatment of chronic rhinitis (inflammation of the internal tissues of the nose, accompanied by mucous secretions). In this case, the drug facilitates breathing and prevents stagnant processes in the nasal passages.

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Release form

"Atrovent" is not among the natural preparations, to which many patients are treated with greater favor, considering them to be the safest drugs. In the composition of the preparation we find synthetic components:

• As the main active ingredient is ipratropium bromide, known to many in connection with the popular drug for emergency care for bronchial spasms and bronchial asthma called "Berodual." In the preparation "Atrovent" this substance is included in the form of monohydrate.
• Additional components in the preparation, depending on the form of release, can be:
  • purified water, benzalkonium chloride as a preservative, disodium adetate stabilizer, sodium chloride, hydrochloric acid (for a solution form)
  • prepared water, ethanol, citric acid, tetrafluoroethane as a propellant (for the composition in the aerosol).

In what forms of release can you find often prescribed medication in pharmacies:

• Solution in vials of darkened glass. Vials with a cap-dropper and a screw cap can have a volume of 20, 40 and 100 ml. 1 ml of the pharmacy solution contains 261 μg of ipratropium bromide in the form of monohydrate (in terms of the anhydrous composition this will be 250 μg). The drug is intended for inhalation procedures.
• Aerosol in a metal bottle containing a mouthpiece and a metering valve. The volume of the bottle can be 10 or 15 ml. The first contains 200 doses of the drug, the second - 300 doses. Each dose contains 20 mg of active ingredient. Aerosol is also used for inhalations that do not require additional equipment.
• Aerosol for inhalation in rhinitis (the drug is injected into the nasal cavity) with a nasal nozzle. Vials can contain 10,15, 20 and 30 ml, which corresponds to 200, 300, 400 and 600 doses.
• Capsules with ipratropium bromide powder, used for dry inhalations in special nebulizers. The package contains 100 capsules. Each capsule contains 200 μg of active ingredient.

The solution and composition in aerosols "Atrovent" for inhalations is a transparent unpainted liquid in which there are no crystalline particles. Capsules contain a whitish, fine powder.

Any form of release (aerosol, solution or drops, Atrovent powder) can be used for inhalation. Aerosols are convenient because they can always be taken with them to work or a walk. A solution can be used in nebulizers or centralized oxygen systems.

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Pharmacodynamics

Acquiring the drug "Atrovent" for inhalations a person, of course, wants to know what therapeutic effect the drug has and how long the effect will last from its application. The pharmacodynamics (mechanism of action) of the drug will help us to answer the first question.

Producers of the medicine, and this is the German company BOEHRINGER INGELHEIM INTERNATIONAL, claim that their drug is an effective bronchodilator. What does this mean? Bronchodilators call drugs, the action of which is to expand the bronchi (bronchodilation) and relax the musculature of the organ (spasmolytic effect).

The combination of these two effects is due to the anticholinergic properties of the drug. Reflex bronchoconstriction can occur under the influence of various irritating factors (tobacco smoke, cold air, medication administration) or be caused by the response of the vagus nerve. Blocking m-holinoretseptory smooth muscles of the bronchi, the active substance of the drug reduces their tone and prevents violations of airway patency.

Studies of the drug showed that it has no adverse effect on the production of bronchial secretions, gas exchange and mucociliary clearance. There is a slight decrease in the amount of sputum without inhibiting its retreat.

Through the drug, there have been successful attempts to treat such pathologies accompanied by bronchial spasms, like viral bronchiolitis and bronchopulmonary dysplasia in young children, including infants.

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Pharmacokinetics

Now let's talk about the pharmacokinetics of the drug, which may be interesting in the sense that it tells how long it is possible to observe the effect of inhalations by Atrovent and through which organs the drug is excreted from the body.

The drug "Atrovent" is intended for inhalation, thus, from it we stand to wait for local action on the lesion site. Absorption of the drug in the tissue is low. The lungs usually get no more than 30% of the active substance, from which a small part of it penetrates into the systemic bloodstream. The bulk of the drug settles in the oral cavity or enters the gastrointestinal tract, where again it is digested in a small amount.

The drug is not able to penetrate the placental or the blood-brain barrier, which indicates its relative safety.

It must be said that the pharmacokinetic indices describing the distribution of the drug in the body and its systemic effect in this case do not affect the bronchodilator properties of the drug.

Metabolism of the active substance is carried out mainly in the liver. When inhaled, about 70% of the active substance and its metabolites are excreted through the intestine. The kidneys derive mainly inactive metabolites of ipratropium bromide.

Regardless of the concentration of the drug falling into the blood, the effect of the drug can be expected after 10-15 minutes, but it will reach its maximum efficiency only after 1-1.5 hours. On the one hand, this is a short waiting time, but if urgent help is required, such a delay can cost a person's life. So the choice of the drug for emergency care should be stopped on other medicines.

The bronchodilator effect after inhalations can last 5-6 hours, so repeated use of the drug should be done at intervals of 4-6 hours. Forty percent of patients have a significant improvement in lung functional capacity (exhalation rate and expiratory air volume).

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Dosing and administration

The drug "Atrovent" for inhalations has a specific effect, so it is prescribed only in difficult situations, when there is a risk of breathing due to bronchial obstruction or spasm of smooth muscles of the respiratory tract. The use of the drug for cough and bronchitis without obstruction is undesirable. In any case, treatment with Atrovent should take place under medical supervision. No wonder because in pharmacies, this strong drug can only be purchased with the prescription of a doctor.

Dosage of the drug for various diseases should be selected individually. This takes into account the patient's condition, the severity of the pathology, the age of the patient and the body's response to the active substance.

Aerosol application "Atrovent" for inhalations. Before releasing the first dose of the drug into the throat, the inhaler bottle should be well shaken. If the inhaler is new and this is its first use, you first need to release a couple of doses into the air. The appearance of a specific cloud indicates that the spray is normal and gives the necessary therapeutic dose. If the medicine is removed from the new vial immediately into the throat, the dosage may not be sufficient because of the undeveloped batcher and the effect will also be minimal, which is dangerous in the case of bronchospasm.

If there was a break in the use of the aerosol, the particles deposited inside the dispenser may prevent the recommended dose from being dispensed. In this case, the first dose is also released into the air.

Patients who are older than 6 years may use the aerosol. It is difficult for young children to learn all the wisdom of using this form of the drug. In addition, the very inhalation administration of the drug in a high dosage (and each dose contains 20 μg of ipratropium bromide as standard) can provoke bronchospasm in them.

Dosage for children and adults in this case will be approximately the same. Usually patients are prescribed 2 injections of the drug (between them there should be an interval of at least one minute) 4 times a day. The maximum number of procedures per day is 12 (2 doses 6 times a day).

How to correctly use the aerosol in the form of a vial with a dispenser and mouthpiece:

• Before use, shaking the can, remove the cap from it.
• Now we will try to breathe out completely the air.
• Turn the balloon down with a mouthpiece and grasp the tip with your lips.
• We take a deep breath and at the same time press on the dispenser, releasing the first dose into the mouth.
• Hold your breath and take the mouthpiece out of your mouth.
• We make a slow exhalation.
• After a minute, repeat the procedure, introducing a second dose into the respiratory tract.

The balloon must contain 200 or 300 doses. It may happen that by the number of doses the drug should have ended, but there remains a small volume of the solution in the vial. Use of the remaining medicine is not recommended, as its pharmacological properties will be much lower than those prescribed in the instructions for doses. In this case, it is more appropriate to replace the can with the drug. It will be very sad if the remaining medicine can not relieve bronchospasm or an asthmatic attack that poses a danger to human life.

In order to avoid surprises during the use of the pocket inhaler, you need to closely monitor the cleanliness of the dispenser and the mouthpiece. They can be washed with clean water or using soap. In the latter case, thorough rinsing with water is necessary.

The nasal inhaler for chronic rhinitis is usually used 3 times a day, injecting a nostril with a nasal nozzle each time for 2 or 3 doses of the drug. The procedure is performed for both nasal passages.

Application of the Atrovent solution for inhalation. Using the drug solution, it should be taken into account that each drop of the drug contains 12.5 μg of the active substance. And each milliliter consists of 20 such drops, i.e. Contains 250 μg of ipratropium bromide.

In the treatment of acute pathologies accompanied by a sudden violation of bronchial patency, the drug, depending on the age and severity of the patient's condition, is used in the following dosages:

• Patients older than 12 years of age are usually prescribed 40 drops of "Atrovent" per procedure. A single dose of ipratropium bromide in this case will be 500 μg.
• Children above 6 and under 12 years of age spend 1 ml (20 drops) per procedure. A single dose of the active substance in this case will be 250 μg.
• For treatment of babies younger than 6 years of age, the drug consumption will be from 8 to 20 drops per procedure (100-250 μg).

The number of procedures per day and the size of the intervals between them should be prescribed by the attending physician on the basis of the severity of the disease and age indices. It is allowed to use Atrovent together with beta-adrenomimetics.

Supportive therapy involves the use of the drug in the same doses, but the multiplicity of the procedures will be no more than 4 per day, which allows you not to exceed the maximum allowable daily doses that for children under 12 years of age are 4 ml of solution, and for adults - 8 ml.

But that is not all. For inhalation procedures ipratropium bromide solution is not used in its pure form. Inhalations are performed with Atrovent and saline. That is, take the recommended dose of the drug, add saline (sodium chloride solution with a concentration of 0.9%) in the volume necessary to obtain 3.5-4 ml of the ready-made inhalation composition.

It is most effective to use inhalation with a nebulizer (any model is suitable). In this case, the dosage regimen in different instruments may be slightly different, so you must first study the instructions to the nebulizer.

The duration of the inhalation will depend on the patient's condition and the rate of consumption of the prepared liquid formulation for inhalation. Mix the drugs used in one solution for the procedure, you need to immediately before inhalation. Remaining in the nebulizer solution is not suitable for the next procedure, so it must be drained into a sink and thoroughly rinsed.

The finished composition can be stored in the refrigerator for no more than a day. In this case, before pouring the solution into the inhaler, it is heated in a water bath to room temperature.

Use for inhalation treatment of capsules with powder. Dry inhalation powder is carried out using a special inhaler with a nozzle mouthpiece. At the same time, the particles of the drug enter the respiratory tract during a deep sharp inhalation. Before laying the capsule in the inhaler, it must be pierced, so that the particles of the drug are released gradually.

During inhalation, the mouthpiece of the inhaler should be in the patient's mouth. Before exhaling, you need to hold your breath and take out the mouthpiece. The duration of the procedure is limited by the amount of powder in the capsule. Once it is over, inhalation can be stopped. Multiplicity of procedures is usual - from 3 to 4 times a day.

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Application for children

The drug "Atrovent", prescribed for inhalations for bronchial obstruction and bronchospasm, is considered a relatively safe medicine, and the low absorption of its components in the body allows the use of the drug even for the treatment of small children without fear for the health and development of the baby.

According to the annotation to the medicine, "Atrovent" in aerosol is allowed to use from the age of 6 years, and in solution - from 5 years. But given the lack of action-hazardous activities for the child, it began to be used at an earlier age (mainly a solution for inhalation in nebulizers, which are effective and convenient for treating babies).

This is somewhat contrary to the instructions, but the results of the studies indicate that the inhalation solution does not harm the child's body. Conversely, with bronchial asthma with the production of a large amount of mucus in the bronchi (the so-called "wet asthma," often diagnosed in childhood), the drug helps to reduce the amount of sputum slightly and thus prevent the bronchial obstruction, especially in children who do not yet know how to clear the throat well .

"Atrovent" refers to the category of drugs that do not have a negative effect on the work of the cardiovascular system. In our difficult times, increasingly such pathologies make themselves felt even in early childhood. The use of the Atrovent solution for inhalation in a nebulizer in the treatment of such children allows them to receive professional help in the treatment of asthma and obstructive bronchitis without worsening the condition of their heart.

And nevertheless there are some pathologies at which to apply a preparation it is necessary with special accuracy and strictly under the supervision of the doctor. Such pathologies include chronic lung diseases, brain damage, Down's disease, cerebral palsy because of the danger of worsening the condition of such patients.

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Use Atrovent for inhalations during pregnancy

The use of the drug in pregnancy and lactation is not prohibited, because clinical studies with doses several times higher than safe did not show the toxic effect of the drug on the fetus in the womb. There was no teratogenic effect on the developing organism, i.e. The drug is not able to cause impaired development of the fetus.

And yet the medicine is a medicine. Doctors are careful not to prescribe the drug in the first trimester of pregnancy, when the risk of miscarriage is high, and the main organs and systems of the child are in the stage of formation. All the same, every human organism (even this small embryo) is individual and it is difficult to predict its reaction to a drug.

In the following months, the appointment of the "Atrovent" takes place according to the generally known principle, choosing the lesser of evils, i.e. If there is a real threat to the life of the mother and there is no way to choose an even safer medicine.

As for breastfeeding, there is no information that ipratropium bromide is able to penetrate into mother's milk. And yet it will be safer if possible to abstain for the duration of treatment from breastfeeding.

Contraindications

"Atrovent" for inhalations, although considered a fairly safe drug, some restrictions on its use still exist. And although these restrictions are very few, they can not be ignored.

The main contraindication to use, applicable to absolutely all medicinal products (synthetic and natural) is hypersensitivity to at least one of the main or auxiliary components. Do not prescribe the drug and those patients who have an anamnesis has an unusual reaction to atropine and its derivatives, due to individual intolerance.

The drug can be used, but under the condition of caution (preferably under the supervision of a doctor) with such pathologies as:

• closed-angle glaucoma, characterized by the pathology of the iris in combination with high intraocular pressure,
• hyperplasia of the prostate (excessive growth of prostate tissue),
• obstruction of the urinary tract caused by stenosis or kidney and bladder disease with the formation of stones (urine or nephrolithiasis).

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Side effects Atrovent for inhalations

Since the drug "Atrovent" is used for inhalations, it is first of all worth mentioning the side effects associated directly with the procedure. The smallest particles of the drug that a person inhales during inhalation procedures can irritate the throat and bronchial mucosa a little, plus the bronchodilating effect helps to get rid of sputum, which can cause a reflex cough.

The use of inhaled bronchodilators in rare cases can provoke a back reaction in the form of bronchospasm. In the preparation "Atrovent" there are 2 components that cause a similar reaction: the preservative benzalkonium chloride and the disodium adetate stabilizer.

Absorption of the drug into the blood is very low, so it does not cause serious systemic reactions. Most often, patients complain of headaches and dizziness, as well as the cough, throat irritation, dry mouth of the mouth mentioned earlier. Often, the drug provokes nausea and impaired motility of the gastrointestinal tract, caused by the ingestion of drug particles into the digestive system and the depressing effect on sensitive receptors.

Much less frequent complaints are about increased intraocular pressure and reversible vision problems, increased heart rate, laryngeal edema and respiratory tract cramps, vomiting and stool disorders. Perhaps the appearance of non-severe allergic reactions in the form of edema and hyperemia of tissues in the area of application, rash and itching on the skin. Angioedema and anaphylactic reactions develop very rarely.

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Overdose

Despite the fact that the drug Atrovent for inhalations is used locally, some readers may be concerned about the unpleasant event, such as an overdose of the drug, which in severe cases, in the absence of timely assistance, can cost a person's life. Regarding the drug described, it can be said that it is not worth worrying about this, because even that part of ipratropium bromide, which enters the lungs and intestines, has a low absorption.

Doses higher than recommended, with intravenous administration (ie, the drug enters directly into the blood and can have a systemic effect), and then did not show the appearance of life-threatening symptoms. So inhaled treatment is unlikely to be associated with the danger of an overdose.

The tenth part of the active substance, usually penetrating into the lungs and blood, is capable, except in rare cases, of causing dryness of the oral mucosa, minor reversible accommodation disorders and tachycardia (increased heart rate). In this case, symptomatic treatment is performed. At the end of the use of "Anthrovent" the functions of the organs are restored without consequences.

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Interactions with other drugs

The drug "Atrovent", used for inhalation in diseases of the upper and lower respiratory tract, is characterized by a strong anticholinergic effect. It can be combined with other drugs with a similar effect, but for a short time and under the supervision of a doctor who, if necessary, adjusts the dose of medications to avoid the development of various side effects.

The drug is considered a bronchodilator with sufficient efficacy. But some types of medicines can further enhance its effect. It is about the derivatives of xanthine (the same theophylline) and beta-adrenomimetics. To strengthen the anticholinergic effect of "Atrovent" drugs for the treatment of Parkinson's disease, quinidine, tricyclic antidepressants are capable. Applying these drugs together, you need to be careful. In this case, the dosage of the bronchodilator can be slightly reduced.

It is not recommended to combine the use of Atrovent and beta-adrenomimetics in patients with closed-angle glaucoma. Such co-treatment can promote increased intraocular pressure.

It is not desirable to use the described preparation and cromoglycic acid simultaneously, because such a combination can reduce the effectiveness of both drugs.

It is possible to use as a part of combined inhalations with mucolytics and expectorants (ambroxol, bromhexidine, etc.).

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Storage conditions

Preparations of any form of release are packed in containers that protect the medicinal composition from sunlight, therefore additional protection is usually not required. The preparation is not too sensitive to the temperature regime, and therefore it can be stored even at relatively high temperatures (up to 30 degrees). But the manufacturer does not recommend freezing the medicine.

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Special instructions

It is undesirable to use "Atrovent" for inhalations in order to provide emergency assistance during an attack of suffocation. If the medicines that produce the required effect are faster, because in this case every minute counts.

Using a solution for inhalation in a nebulizer, you need to properly select the nozzles. It is better if it is a mouthpiece or a mask selected strictly in size, which will prevent unwanted particles of the drug from entering the eyes. The drug can cause not only irritation of the eyes (pain, redness and swelling of the mucosa appear), but also some visual impairment (mydriasis, impaired vision, the appearance of multicolored halos in front of the eyes, accommodation paresis, etc.), and increased intraocular pressure . Therefore, the eyes should be protected by all, and even more so for those who suffer from glaucoma.

If the above symptoms have appeared (and they may indicate the development of glaucoma), you should consult a doctor for the appointment of eye drops that relieve irritation and reduce intraocular pressure. Ideally, by prescribing this medication to patients, the doctor should warn them about such complications and explain how they can be avoided using the drug in the aerosol or solution correctly.

Patients with obstruction of the urinary tract should use the drug strictly under the supervision of a doctor, because in their body the drug can stay longer than usual. In cystic fibrosis, there is a risk of a decrease in GI motility, which also requires caution and monitoring of the patient's condition.

The preparation in the form of an aerosol is issued in freonless and freon form, which differ somewhat in taste, but not in the effect. It is also necessary to warn patients about this.

Some side effects of the drug may be dangerous for patients whose activities require increased attention and concentration. Therefore, during the inhalation treatment it is worth to refrain from driving and performing potentially dangerous work.

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Shelf life

Use "Anthrovent" for inhalation is possible during the expiration date indicated on the package, which is 3 years. After this period, the effectiveness of the drug is reduced, but the danger of unwanted effects increases.

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Analogues

"Atrovent" is not the only drug in bronchodilator action, which can be successfully used for inhalations in pathology of the respiratory system with the likelihood of developing airway obstruction or bronchospasm. A similar effect is characteristic of such preparations:

• "Ipravent" (available as a compact aerosol with a dosed supply of the drug),
• "Ipratropium" (has the form of release in the form of a solution, also used in inhalation procedures),
• "Iprimol" (a drug in the form of a solution for inhalation),
• "Spiriva" (a drug released in capsules and in the form of an inhalation solution),
• "Trventola" (a drug in an aerosol for inhalations in pathologies of the lower respiratory tract),
• "Truvent" (another aerosol with a bronchodilator effect),
• "Berodual" (a two-component preparation in the form of an aerosol and a solution for inhalations).

We listed the analogues of the Atrovent for inhalations that are similar in composition and effect. Preparations that have the same active substances are considered interchangeable, but care must also be taken for the dosage of the drug and the auxiliary components for which the organism can also respond with intolerance reactions. In any case, the replacement of one drug with another is desirable only with the permission of the attending physician.

The most popular analogue of "Atrovent" is "Berodual", which is often prescribed for bronchial obstruction and for relief of asthma attacks. In addition to ipratropium bromide (a substance with an atropine-like effect, which is designed to reduce the sensitivity of acetylcholine receptors to irritants that cause bronchospasm), there is another active substance in the formulation. This fenoterola hydrobromide, which helps relax the smooth muscles of the bronchi and reduces the inflammatory process in the airways.

It is believed that such a double action will give a stronger antispasmodic effect and act faster than a one-component Atrovent. Nevertheless, the presence of an additional antispasmodic component somewhat expands the list of pathologies in which the drug should be used with extreme caution because of the existing risk of complications.

In pregnancy, "Atrovent" will be even safer than "Berodual." Spasmolytics can adversely affect the ability of the uterus to contract during delivery, pushing the baby out, so in the last months of pregnancy, the choice will be in favor of Atrovent.

Reviews

Perhaps, "Atrovent" for inhalations with bronchial asthma, bronchial obstruction and pathologies with a high probability of bronchospasm is not prescribed as often as the popular "Berodual", however, this drug is not much inferior in effectiveness to its counterpart.

Those who have experienced a medicine on themselves or their relatives for the treatment of bronchial obstruction note that a significant improvement in the condition of the patient comes after 2 inhalations. And the effect turns out to be quite stable, so there is no need to use the drug often and for a long time.

A good effect is provided by complex inhalation procedures. Atrovent quickly and effectively increases the clearance of the bronchi, which facilitates the work of anti-inflammatory drugs, expectorants, mucolytics and antibiotics. Medications are able to penetrate deeply into the respiratory tract, reducing swelling and inflammation of the mucosa and removing from the bronchi phlegm with the microbes trapped in it.

The drug is considered safe for the treatment of children of any age and future mothers, what further attracts the attention of doctors and parents of sick children. The rapid removal of the child's tormenting symptoms can not be unattractive to the parents. Especially if the treatment does not lead to negative consequences for other kid's organs, as is often the case with chemical medicines.

The drug is also suitable for preventing asthma attacks. In that case, it is recommended to use it for 1-2 hours before a lot of physical exertion or activities that can cause a strong excitement and an attack of suffocation. As an emergency aid of inhalation with Atrovent, it is better to use in addition to drugs from the group of beta-adrenoactivators (for example, Ventolin). The effect will be stronger and will come faster, preventing hypoxia of the organs due to lack of oxygen into the lungs.

Asthmatic patients note that prolonged use of the drug even at high inhalation rates did not lead to overdose and the occurrence of delayed side effects.

"Atrovent" for inhalations is a completely safe and convenient way to combat diseases that can provoke an attack of choking dangerous to human life. Convenient forms of release, affordable price and the possibility of treatment with a drug of adults, old people and children make the drug a very useful acquisition. Still, medications, even the safest ones, are necessary only with the permission of a qualified doctor, which will help to avoid unpleasant surprises.

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