GP Respiratory

Question 1

Explain simply asthma and what type of reaction it is?

Answer 1

• Asthma is defined as recurrent but reversible obstruction to the airways in response to substances that are not necessarily noxious
• Asthma is a type 1 hypersensitivity reaction involving eosinophilic inflammation and a TH2 response

Question 2

Who is more at risk of getting asthma?

Answer 2

not fully understood
part of atopic triad - asthma, eczema, hay fever
increased risk with family history
asthma exacerbation generally have triggers e.g. pollen, dust, air pollution, cold weather

Question 3

Symptoms and signs of asthma?

Answer 3

• Tight chest
• Widespread wheeze
• Dry cough
• Diurnal variation in symptoms (asthma is worse at night but their peak flow will be worse in the morning after they wake up having had worse asthma over night)
• Symptoms associated with triggers

Question 4

Investigations for asthma?

Answer 4

• FEV1 is reduced but FVC is normal, the FEV1/ FVC ratio is reduced
• Should have reversibility on administration of a bronchodilator
• Peak flow testing is done and people may be given a peak flow diary

Question 5

Define FEV1 and FVC?

Answer 5

FEV1= Forced expiratory volume in one second, the volume exhaled in the first second after deep inspiration followed by maximal expiration
FVC= Forced vital capacity, the total volume of air a patient can exhale

Question 6

Explain FEV1, FVC and the ratio in asthma?

Answer 6

In asthma the FEV1 and the FEV1/FVC ratio is reduced, but FVC is normal, the person has an obstruction so can’t get air out as quickly but they can still get all the air out

Question 7

Explain when spirometry is used vs peak flow in asthma?

Answer 7

Spirometry is used to measure FEV1 and FVC and useful in diagnosis. Peak flow is a method that can be used at home by the patient.

Question 8

Define peak flow?

Answer 8

Peak flow is a measure of how fast you are able to forcefully exhale after full inhalation.

Question 9

Management of asthma?

Answer 9

• Those with a diagnosis of asthma should be prescribed a SABA for relief of symptoms
• The frequency of use of a SABA is a good measure of asthma severity and control
• If a preventer is needed inhaled ICS has been shown to be the most effective and is first line in adults and most children
• Can add on other preventer therapies which seems to be patient dependent on what is prescribed e.g. Leukotriene receptor antagonists (montelukast), LABAs, Sodium cromoglicate and theophylline (methylxanthines)
• Very unresponsive asthma may be referred for monoclonal antibody treatment

Question 10

Explain how to carry out peak flow respiratory function test?

Answer 10

• Find a comfortable position – sitting or standing – be in same position each time
• Push the pointer back to the first line of the scale nearest the mouthpiece and make sure your finger isn’t covering it
• Hold the peak flow meter horizontal
• Breathe in deeply as you can and place lips tightly around the mouthpiece
• Breathe out as quickly and as hard as you can
• When you’ve finished breathing out, make a note of your reading
• This should be repeated 3 times and the highest of the 3 measurements recorded

Question 11

Explain MDI and Soft Mist Inhaler Technique?

Answer 11

• Shake the MDI vigorously for five seconds before each puff (you don’t need to shake a soft mist inhaler)
• Inhale through the mouth when breathing in medication not the nose
• Keep tongue under the mouthpiece so that it doesn’t block the opening of the mouthpiece
• Start taking a slow deep breath at the same time you press down on the medication canister
• Hold your breath for as long as comfortable (5 to 10 seconds) then exhale
- if taking a second dose wait 30s and repeat

Question 12

Explain DPI Inhaler technique?

Answer 12

• Breathe out slowly and completely (not into the mouthpiece)
• Place the mouthpiece between the front teeth and seal the lips around it
• Breathe in through the mouth quickly and deeply over two to three seconds
• Remove the inhaler from the mouth, hold your breath for as long as possible (4 to 10 seconds)
• Breathe out slowly

Question 13

Explain how to use a spacer?

Answer 13

• Put inhaler into the hole at the back of the spacer
• Put lips around the mouthpiece of the spacer to make a tight seal and begin breathing in and out
• Press the canister on the inhaler and breathe in and out steadily into the spacer 5 times
- if need second dose wait about 30s to a minute before next dose

Question 14

What can chronic asthma results in?

Answer 14

Chronic asthma can cause permanent changes to the airway such as smooth muscle hypertrophy, increased mucus and epithelial damage with subepithelial fibrosis

Question 15

What is COPD a combination of?

Answer 15

chronic bronchitis and emphysema

Question 16

Define chronic bronchitis? What is thought to cause it?

Answer 16

• Chronic bronchitis is long term inflammation of the bronchi
• It is usually however a clinical diagnosis defined as a productive cough for at least 3 months of the year for at least 2 years
• The main cause is smoking where the chemicals from the smoke stimulate hypertrophy and hyperplasia of the bronchial mucinous glands and goblet cells, there is also a reduction in the height of the cilia

Question 17

What is emphysema? What is thought to cause it?

Answer 17

• Emphysema is defined as permanent dilatation of the air spaces distal to the terminal bronchioles due to destruction of their walls without fibrosis
• The main cause of emphysema is smoking which is thought to cause an imbalance between protease (which break down lung connective tissue) and anti-protease activity
• Lungs are hyperinflated due to trapped air, this can also be seen on post mortem

Question 18

Symptoms and signs of COPD?

Answer 18

• Productive cough
• Breathlessness
• Wheeze
• Frequent infective exacerbations
• Use of accessory muscles of respiration
• Chest expansion is poor
• Hyperinflation
• Loss of cardiac and liver dullness (lungs hyperinflated over these)

Question 19

Investigations for COPD?

Answer 19

• Mainly a clinical diagnosis based on symptoms and history
• Obstructive pattern on spirometry (low FVC, very low FEV1 and low FEV1/FVC ratio)
• Reduced peak flow
• Generally poor reversibility with bronchodilator (some COPD may be reversible and can then be difficult to distinguish from asthma)
• CXR is usually normal unless advanced disease

Question 20

Management of COPD?

Answer 20

• Before pharmacological therapy must offer smoking cessation, pneumococcal and influenza vaccines, offer pulmonary rehab, optimize treatment of co-morbidities
• If struggling with breathlessness and it is limiting their exercise can offer inhaled therapies
• LABA plus LAMA for those struggling with breathlessness
• LABA plus LAMA plus ICS (triple therapy for those with eosinophils or those who have frequent exacerbations

Side note: trellegy ellipta is triple therapy and breo ellipta inhaler is dual therapy

Question 21

Management of an acute exacerbation of COPD?

Answer 21

iSOAP
• Ipatropium
• Salbutamol
• Oxygen
• Amoxicillin (not necessarily because it is bacterial but because there is high risk of secondary bacterial infection - NICE guidelines say only give this if purulent sputum or signs of pneumonia)
• Prednisolone

Question 22

List some side effects of salbutamol?

Answer 22

trembling
tachycardia
hypokalaemia
hyperglycaemia

Question 23

What is a side effect of inhaled ICS?

Answer 23

oral thrush