Chronic Resp

Question 1

Presentation of asthma

Answer 1

Cough, wheeze, SOB
Worse in morning and evening
Atopy in hx and FHx
Smoker
*chronic inflammatory airway disease characterised by intermittent airway obstruction and hyperreactivity

Question 2

Ix for asthma

Answer 2

Bloods
PEFR
- varies by/increases >20% for >3 days/weeks over several weeks
Spirometry
- FEV1:FVC<70%
- reversibility, 12% pre- and post- bronchodilator spirometry

Question 3

Rx pathways for asthma

Answer 3

SABA => SABA + ICS =>
SABA + ICS + LTRA => LABA + ICS +/- LTRA =>
LABA + increase ICS +/- LTRA => trials => oral CS

SABA (short acting B agonist) - salbutamol
ICS (inhaled CS) - beclometasone, budesonide
LTRA (leukotriene rec antagonist) - montelukast
LABA (long-acting) + ICS - symbicort (budesonide/formoterol)
oral CS - prednisolone

Question 4

How are acute asthma attacks classified?

Answer 4

Moderate
- PEF 50-75%
Acute-severe
- PEF 33-50%
Life-threatening
- PEF <33%
Near fatal
- pCO2 raised
*peak expiratory flow

Question 5

Ix for acute asthma attacks

Answer 5

Basic obs
PEF
O2 sat and maintain SpO2 at 94-98%
ABG (repeat if PaO2 <8kPa unless SpO2 <92% or PaCO2 normal/raised or pt deteriorates)
serum K+ and glucose

Question 6

Rx for acute asthma attack

Answer 6

Nebulised salbutamol 5mg
Nebulised ipratropium bromide 0.5mg
Oral prednisolone 40-50mg
IV hydrocortisone 100mg
=>
IV magnesium sulphate
Call senior help
=>
IV aminophylline
=>
ITU + intubation

Question 7

COPD presentation

Answer 7

SOB, productive cough, some wheeze
Older age
Heavy smoking status
Barrel chest
NO clubbing

Question 8

How is COPD classified?

Answer 8

All have a FEV1/FVC < 0.7

FEV1 readings:
Mild = >80%
Moderate = 50-79%
Severe = 30-49%
Very severe = <30%

Question 9

Ix for COPD

Answer 9

Spirometry (determine severity)
Bloods, ABG (check for alpha-1 antitrypsin)
ECG (assess cardiac status for cor pulmonale)
CXR (lung reduction associated with increased survival)
Serial peak flow measurements

Question 10

Rx based on severity

Answer 10

Mild => SABA/SAMA (salbutamol, ipratropium bromide)
Moderate => SABA + LABA/SAMA + LAMA (tiotropium/salmeterol)
Severe => LABA + LAMA/LABA + ICS (symbicort)
Very severe => LAMA + LABA + ICS (tiotropim + symbicort)

Question 11

Mx of COPD

Answer 11

General
- smoking cessation
- annual influenza vaccine
- pneumococcal vaccine
Improve survival
- smoking cessation
- long term O2 therapy (15hrs/day)
- lung volume reduction surgery

Question 12

When would a COPD pt start oxygen therapy?

Answer 12

1) pO2 < 7.3kPa

2) pO2 7.3-8kPa + one of the following:
- secondary polycythaemia
- nocturnal hypoxaemia
- peripheral oedema
- pulmonary HTN

Question 13

Acute exacerbation of COPD rx

Answer 13

(Blue Venturi) 24% O2
=>
Nebulised salbutamol 5mg
Nebulised ipratropium bromide 0.5mg
Oral prednisolone 40-50mg
IV hydrocortisone 200mg
=>
IV amoxicillin
=>
500mg IV aminophylline
=>
BiPaP (NIV) (type II resp. failure)

Question 14

Name types of interstitial lung diseases

Answer 14

Idiopathic pulmonary fibrosis
Hypersensitivity Pneumonitis
Sarcoidosis
Pneumoconiosis

Question 15

What may present in the hx of a pt with idiopathic pulmonary fibrosis?

Answer 15

SOBOE, dru cough, no wheeze 
Clubbing
Animal/vegetable dusts
Smoking status baad
Occupational exposure to metal/wood
Chronic microaspiration
Drugs: bleomycin, methotrexate, amiodarone

Question 16

Ix for idiopathic pulmonary fibrosis

Answer 16

Bloods, ABG, biopsy
CXR (ground-glass, reticulonodular, cor pulmonale, honeycombing)
High-res. CT (ground-glass)
Lung function tests (restrictive patterns)

Question 17

How may hypersensitivity pneumonitis present?

Answer 17

Acute +/- chronic hx
Keeps pets
SOBOE, dru cough, fever
*Picks mushrooms, birdkeeper, farmer, plumber, maltworker

Question 18

Ix for hypersensitivity pneumonitis

Answer 18

Bloods, ABG
CXR (ground-glass)
High res. CT (ground-glass)
Broncho-alveolar lavage (increased cellularity)
Lung function tests (restrictive pattern)

Question 19

How may pneumoconiosis present?

Answer 19

SOB, cough
Asymptomatic generally
Long latency
Coal worker, builder (silicosis, asbestosis)

Question 20

Ix for pneumoconiosis

Answer 20

CT (fibrotic changes)
CXR (micronodular mottling => bilateral lower zone reticulonodular shadowing + pleural plaques
Lung function tests (restrictive patterns)

Question 21

How may CXR differentiate between silicosis and asbestosis?

Answer 21

Asbestosis
- fibrotic changes, not just plaques
Silicosis
- eggshell calcification, micronodular shadowing

Question 22

Presentations of sleep apnoea

Answer 22

Chronic fatigue
Truck driver
Unrefreshed sleep
Snoring
Obesity, smoker, alcohol
Enlarged tonsils, macroglossia, Marfan's syndrome

Question 23

Ix and Rx for sleep apnoea

Answer 23

Ix

• TFTs
• sleep study: airflow monitoring, HR, pulse ox., resp. effort

Rx

• lose weight
• CPAP if real bad (damn)

Question 24

What is sleep apnoea?

Answer 24

Recurrent collapse of pharyngeal airway and apnoea (cessation of airflow for 10s) during sleep, followed by arousal from sleep

Question 25

A 17 year-old girl presents to the local A&E complaining of worsening shortness of breath, despite use of what she describes as her ‘blue inhaler’. On examination her oxygen saturations are 95%, she is afebrile and has a BP of 101/67. The attending physician takes an ABG and the results are shown below. Grade the severity of this patient’s asthma attack.

pH 7.25
pCO2 7.4 kPa (4.5-6.0)
pO2 10.4 kPa (>10.5)
HCO3 23 mmol/l

a) I cannot tell from the information available
b) Moderate
c) Acute severe
d) Life threatening
e) Near fatal

Answer 25

e) Near fatal

Question 26

A 26-year-old bus driver presents to the GP complaining of a worsening shortness of breath. On examination, the patient is afebrile, has a BP of 110/85 and has a marked wheeze on auscultation. The only medications the patient is on is Salbutamol, PRN. What is the next most appropriate treatment step as per the treatment guidelines for this condition?

a) Replace the blue inhaler with a brown, low-dose inhaled corticosteroid
b) Replace the blue inhaler with a long-acting beta-agonist medication
c) Replace the blue inhaler with a long-acting muscarinic agonist medication
d) Add an inhaled low-dose corticosteroid to her medications, taken OD
e) Add oral corticosteroid tablets to her medications, taken OD

Answer 26

d) Add an inhaled low-dose corticosteroid to her medications, taken OD

Question 27

A 72-year-old man attends the GP complaining of increased shortness of breath and a cough productive of clear sputum. The GP notes the gentleman has a history of diagnosed COPD and decides to review his medications. The man hands the GP two inhalers, one a SABA and the other a LABA. After conducting spirometry, the GP calculates an FEV1 of 40% expected. What is the next most appropriate treatment step?

a) Replace the SABA with a LAMA
b) Replace the LABA with an LAMA
c) Add a LAMA
d) Add an ICS
e) I need to conduct more tests to determine what medications to review

Answer 27

a) Replace the SABA with a LAMA

Question 28

Which of the following is NOT a respiratory cause of clubbing?

a) Squamous cell lung cancer
b) Interstitial lung disease
c) COPD
d) Cystic fibrosis
e) An empyema (lung abcess)

Answer 28

c) COPD

Question 29

A 65-year-old man with a medical background of benign prostatic hyperplasia, presents to the GP with a 1 week history of worsening shortness of breath on exertion. He has a temperature of 38.5C, reports no weight loss but does mention some mild fatigue from his ‘pet pigeons keeping him up all night’ recently. On auscultation, the GP can determine fine, bi-basal inspiratory crackles. What is the most likely diagnosis?

a) COPD
b) Lung cancer
c) Bronchiectasis
d) Hypersensitivity pneumonitis
e) Idiopathic pulmonary fibrosis

Answer 29

d) Hypersensitivity pneumonitis

Question 30

A tall 26-year-old woman comes into the GP complaining of chronic fatigue. Upon further questioning she reports that she ‘can never get a good night’s sleep’ and that she tends to fall asleep a lot at her workplace as a call centre customer service representative. She also mentions that she thinks it may have something to do with a condition her mother had. The only significant finding upon examination is patches of stretchy skin, especially around the neck area. What is the most likely underlying condition leading to disrupted sleep?

a) Obesity
b) Bad sleeping position
c) Marfan’s syndrome
d) Down’s syndrome
e) Chronic fatigue syndrome

Answer 30

c) Marfan’s syndrome

* leading to sleep apnoea