Resp Flashcards
A junior doctor wants to prescribe a beta blocker in a patient with long-standing asthma. You explain to the doctor that beta blockers need to be used with caution in patients with asthma. What is the clinical reason that beta blockers are used in caution with asthmatic patients?
A) Beta blockers may affect the patient’s hepatic function
B) Beta blockers may affect the patient’s renal function
C) Beta blockers may cause bronchoconstriction
D) Beta blockers may cause bronchodilation
E) Beta blockers may mask symptoms of hypoglycaemia by causing bradycardia
C
RATIONALE: BETA BLOCKERS TARGET BOTH B1 AND B2
RECEPTORS. B1 RECEPTORS ARE MORE CARDIAC IN NATURE,
WITH B2 RECEPTORS BEING RESPIRATORY IN NATURE.
BLOCKING AIRWAY B2-RECEPTORS CAN CAUSE SEVERE AND
SOMETIMES FATAL BRONCHOCONSTRICTION. WHILST E IS
CORRECT, IT IS NOT RELEVANT IN THIS SCENARIO AS THE
PATIENT, TO YOUR KNOWLEDGE, IS NOT DIABETIC. A AND B
ARE INCORRECT, AND D IS CONTRADICTORY.
You are a ward pharmacist, and a patient has been rushed into A&E with suspected drug toxicity. The patient takes theophylline, and the junior doctor asks you which symptoms are indicative of theophylline toxicity. After reading through the medical clerking notes, you notice that some of the symptoms noted down aren’t indicative of theophylline toxicity
A) Agitation
B) Convulsions
C) Dilated pupils
D) Pinpoint pupils
E) Seizures
D
RATIONALE: PINPOINT PUPILS ARE OFTEN INDICATIVE OF
OPIOID TOXICITY, ALONG WITH RESPIRATORY DEPRESSION
AND DECREASED CONSCIOUSNESS. ALL OF THE OTHER
OPTIONS ARE INDICATIVE OF THEOPHYLLINE TOXICITY. SEE
THE BNF FOR MORE INFORMATION.
You are a ward pharmacist reviewing patients on the ward that you are covering. You notice that one of the patients admitted who has persistent breathlessness has an electrolyte disturbance. Which of the following electrolyte abnormalities is the most common with salbutamol overuse?
A) Hypocalcaemia
B) Hypokalaemia
C) Hyperkalaemia
D) Hypomagnesia
E) Hyponatraemia
B
RATIONALE: HYPOKALAEMIA IS MOST ASSOCIATED WITH
OVERUSE OF SALBUTAMOL, AND IS ALSO ASSOCIATED WITH
A FINE TREMOR
Which of the following is a long-acting bronchodilator commonly used in the management of chronic obstructive pulmonary disease (COPD)?
A) Albuterol
B) Ipratropium
C) Montelukast
D) Salmeterol
E) Theophylline
D
RATIONALE: ALBUTEROL IS AN EXAMPLE OF A SHORT ACTING
BRONCHODILATOR, IPRATROPIUM IS A SHORT ACTING
MUSCARINIC ANTAGONIST, MONTELUKAST IS A MAST CELL
STABILISER AND THEOPHYLLINE IS AN ADJUNCT IN ASTHMA.
Inhaled corticosteroids are often prescribed for the treatment of asthma. Which of the following is a common inhaled corticosteroid?
A) Betamethasone
B) Budesonide
C) Montelukast
D) Prednisolone
E) Zafirlukast
B
RATIONALE: BETAMETHASONE IS A TOPICAL STEROID.
MONTELUKAST IS NOT A STEROID. PREDNISOLONE IS AN
ORAL GLUCOCORTICOSTEROID, AND IS OFTEN USED IN THE
MANAGEMENT OF ASTHMA, BUT NOT VIA THE INHALED
ROUTE. ZAFIRLUKAST IS NOT AN INHALED CORTICOSTEROID
EITHER, RATHER ANOTHER MAST CELL STABILISER.
What is the primary mechanism of action of leukotriene receptor related medications in the treatment of atopic respiratory conditions?
A) Activation of leukotriene receptors
B) Inhibition of acetylcholinesterase
C) Inhibition of mast cell degranulation
D) Stimulation of beta-2 receptors
E) Suppression of interleukin-1 production
C
RATIONALE: IN THE PATHOLOGY OF ASTHMA, INFLAMMATORY
MOLECULES CALLED LEUKOTRIENES ARE ONE OF SEVERAL
SUBSTANCES WHICH ARE RELEASED BY MAST CELLS WHICH
OFTEN DRIVE BRONCHOCONSTRICTION. ACTIVATION OF THESE
RECEPTORS WOULD TRIGGER BRONCHOCONSTRICTION WHICH
IS COUNTERINTUITIVE. STIMULATION OF BETA-2 RECEPTORS
WOULD HAVE THE SAME EFFECT. THE SUPPRESSION OF
INTERLEUKIN-1 WOULD BE AN ANTI-INFLAMMATORY
RESPONSE, BUT IS NOT RELATED TO THE ACTION OF
LEUKOTRIENE RECEPTOR RELATED MEDICATIONS IN THIS
CONTEXT.
A patient with chronic bronchitis is prescribed a medication to reduce mucus production. Which of the following is a commonly used mucolytic agent in such cases?
A) Acetylcysteine
B) Dextromethorphan
C) Ephedrine
D) Guaifenesin
E) Pseudoephedrine
A
RATIONALE: ACETYLCYSTEINE AND CARBOCISTEINE ARE BOTH
EXAMPLES OF MEDICATIONS USED TO REDUCE MUCUS
PRODUCTION IN CHRONIC BRONCHITIS (I.E. COPD).
DEXTROMETHORPHAN IS APPROPRIATE IN SUPPRESSING DRY
COUGH, GUANFACINE, EPHEDRINE AND PSEUDOEPHEDRINE ARE
APPROPRIATE IN ACUTE CASES.
Which of the following is a the most likely side effect associated with long-term use of inhaled corticosteroids in the management of asthma?
A) Bradycardia
B) HyperthyroidisM
C) Hypokalaemia
D) Oral thrush
E) Osteoporosis
E
RATIONALE: THE ONLY FEASIBLE ANSWERS ARE D AND E. D IS A
COMMON SIDE EFFECT OF INHALED CORTICOSTEROIDS, HOWEVER DOES
NOT TEND TO BE A LONG TERM EFFECT, BUT TENDS TO BE SHORT
TERM AND MITIGATED WITH BETTER INHALER TECHNIQUE. LONG TERM
INHALATED CORTISCOSTEROIDS ARE ASSOCIATED WITH AN INCREASED
RISK OF OSTEOPOROSIS AND ATYPICAL FRACTURES.
A patient with asthma is prescribed a combination inhaler containing both a long-acting beta-agonist and an inhaled corticosteroid. What is the rationale for using this combination therapy?
A) Inhibition of mast cell degranulation
B) Prevention of leukotriene synthesis
C) Rapid relief of acute bronchospasm
D) Stimulation of alpha receptors
E) Synergistic bronchodilation and anti-inflammatory effects
E
RATIONALE: A AND B ARE NOT CORRECT AS THESE
MECHANISMS OF ACTION ARE RELATED TO MAST CELL
STABILISERS. C RELATES TO SHORT ACTING
BRONCHODILATORS. LONG ACTING BETA AGONISTS AND
INHALED STEROIDS WORK SYNERGISTICALLY AS PREVENTERS.
A patient with COPD is prescribed a combination inhaler containing both a LAMA and a LABA. What is the rationale for using this combination therapy?
A) Anti-inflammatory effect
B) Enhanced bronchodilation
C) Inhibition of phosphodiesterase
D) Mast cell stabilisation
E) Prevention of leukotriene synthesis
B
RATIONALE: THERE ARE NO STEROIDS, SO THERE IS NO ANTI-
INFLAMMATORY RESPONSE INVOLVED. OPTIONS C THROUGH
TO E ARE NOT RELEVANT HERE EITHER.
Which of the following medications is an antitussive commonly used to suppress cough reflex in the treatment of respiratory conditions?
A) Carbocisteine
B) Dextromethorphan
C) Ephedrine
D) Guaifenesin
E) Pseudoephedrine
B
RATIONALE: DEXTROMETHORPHAN IS USED TO TEMPORARILY
RELIEVE COUGH CAUSED BY THE COMMON COLD, THE FLU, OR
OTHER CONDITIONS. IT IS ALSO THE ONLY ANTITUSSIVE
WITHIN THE LIST OF OPTIONS.
Which of the following medications is a long-acting muscarinic antagonist (LAMA) used in the maintenance treatment of COPD?
A) Aclidinium Bromide
B) Fluticasone
C) Ipratropium
D) Montelukast
E) Terbutaline
D
RATIONALE: ACLIDINIUM BROMIDE IS CONSIDERED A
MAINTENANCE TREATMENT OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE. IPRATROPIUM IS A SHORT ACTING
MUSCARINIC ANTAGONIST, TERBUTALINE IS A SHORT ACTING
BRONCHODILATOR. MONTELUKAST AND FLUTICASONE ARE
MAST CELL STABILISERS AND INHALED CORTICOSTEROIDS
RESPECTIVELY.
Which of the following is a non-sedating antihistamine that is licensed for the symptomatic relief of seasonal allergic rhinitis in a 10-year-old, assuming there are no other contraindications?
A) Acrivastine
B) Chlorphenamine
C) Loratadine
D) Promethazine
E) Xylometazoline
C
RATIONALE: LORATADINE IS THE ONLY CORRECT ANSWER
OUT OF THESE OPTIONS. ACRIVASTINE , WHILST NON-
SEDATING IS NOT LICENSED FOR USE UNDER THE AGE OF 12.
CHLORPHENAMINE AND PROMETHAZINE ARE BOTH
ANTIHISTAMINES THAT CAN BE USED IN THIS AGE RANGE,
BUT BOTH ARE SEDATING. THIS LEAVES LORATADINE..
A patient is prescribed a combination inhaler containing an ICS and a LABA for the management of asthma. What is the recommended sequence for using these two medications in the inhaler?
A) Alternate between LABA and ICS
B) ICS first, followed by LABA
C) ICS only during acute exacerbations
D) LABA first, followed by ICS
E) Simultaneous administration of LABA and ICS
E
RATIONALE: NOTE THAT IN THE CONTENT OF THE QUESTION,
YOU ARE TOLD THAT THIS IS A COMBINATION INHALER, SO IT
WOULD BE IMPOSSIBLE TO ADMINISTER ONE INGREDIENT
FIRST BEFORE THE OTHER. IT IS ALSO WORTH NOTING THERE
IS NO CLINICAL EVIDENCE TO SUPPORT INHALED
CORTICOSTEROIDS FOR ACUTE RELIEF WHICH RULES OUT C.
A patient is using an MDI with a corticosteroid inhaler. What is an important counselling point to minimize the risk of oral thrush associated with inhaled corticosteroids?
A) Avoid oral hygiene measures
B) Combine it with a leukotriene receptor antagonist
C) Rinse the mouth with water and spit after each use
D) Take the medication on an empty stomach
E) Use the inhaler only during acute exacerbations
C
RATIONALE: ORAL THRUSH IS OFTEN CAUSED BY
CORTICOSTEROID DEPOSITING ONTO THE TONGUE, WHICH CAN
BE DUE TO OVERUSE OF ICS, OR POOR INHALER TECHNIQUE.
THIS CAN BE CIRCUMVENTED BY MAINTAINING ORAL HYGIENE
AND RINSING OUT ONE’S MOUTH WITH WATER POST-
ADMINISTRATION OF EACH DOSE.
Which of the following is a common side effect associated with the use of inhaled anticholinergic agents in the treatment of respiratory conditions?
A) Dry mouth
B) Hypertension
C) Peripheral oedema
D) Sedation
E) Tachycardia
A
RATIONALE: ANTIMUSCARINICS HAVE THE COMMON SIDE
EFFECTS OF DRY MOUTH, DRY EYES, URINARY RETENTION
AND CONSTIPATION.
One of the respiratory consultants starts a patient with severe chronic obstructive pulmonary disorder on azithromycin as prophylaxis. When starting azithromycin, certain monitoring needs to be completed. Which of the following is the least likely required monitoring requirement of azithromycin?
A) Creatinine Clearance
B) Hypokalaemia
C) Hypomagnesia
D) Liver Function Tests
E) QTc Prolongation
C
RATIONALE: RENAL FUNCTION AND HEPATIC FUNCTION BOTH
NEED TO BE MONITORED WHEN COMMENCING
AZITHROMYCIN. AZITHROMYCIN CAN ALSO PROLONG THE QTC
INTERVAL, AND POTASSIUM DISTURBANCES CAN CAUSE
CARDIAC DYSFUNCTION
A patient with COPD is prescribed oxygen therapy to maintain a target oxygen saturation level. What is the goal range for oxygen saturation inatients with chronic respiratory diseases?
A) 80-85%
B) 85-90%
C) 88-92%
D) 90-95%
E) -100%
C
RATIONALE: PATIENTS WITH COPD ARE HYPOXIC DUE TO
CHRONIC BRONCHITIS AND EMPHYSHEMA. GIVING OXYGEN
EXCESSIVELY CAN CAUSE OXYGEN INDUCED HYPERCAPNIA,
WHICH CAN LEAD TO ACIDOSIS. THE ONLY FEASIBLE OPTION
IS C. REFER TO BTS/GOLD GUIDELINES IF UNSURE.
A patient with allergic rhinitis is prescribed an intranasal corticosteroid. What counselling point is the most important regarding the technique of administration to maximize efficacy?
A) Administer it with a spacer device.
B) Direct the spray toward the septum.
C) Alternate nostrils with each dose
D) Use the spray only during acute exacerbations
E) Inhale slowly deeply after administration
E
RATIONALE: A SPACER IS NOT RLEVANT AS THE
CORTICOSTEROID IS INTRANASAL. STEROID NASAL SPRAYS
ARE ALSO ADVISED TO BE DEVIATED AWAY FROM THE
SEPTUM. C AND D DO NOT HAVE MUCH EVIDENCE BEHIND
THEM.
A patient with asthma is prescribed an inhaled corticosteroid. What is the primary benefit of inhaled corticosteroids over oral corticosteroids in the treatment of asthma?
A) Enhanced bronchodilation
B) Improved patient adherence
C) Long duration of action
D) Rapid onset of action
E) Systemic side effects are minimised
E
RATIONALE: INHALED CORTICOSTEROIDS WORK AT THE SITE OF ACTION
OF BRONCHOSPASM AND ACUTE INFLAMMATION, I.E. THE LUNGS.
ENHANCED BRONCHODILATION IS NOT THE PRIMARY MECHANISM BY
WHICH CORTICOSTEROIDS WORK. WHETHER PATIENT ADHERENCE IS
BETTER IN INHALED FORMULATIONS IS DEBATABLE; RAPID ONSET OF
ACTION IS A LIKELY BENEFIT, BUT IS NOT THE PRIMARY ADVANTAGE
OVER ORAL COFRTICOSTEROIDS.
A patient with asthma is started on MART therapy, using a Fostair Nexthaler (Beclomethasone 100mcg and Formoterol 6mcg). The patient was previously on a Fostair 100/6 evohaler and salbutamol 100mcg/dose inhaler. The patient asks for your advice on how to use his new inhaler and what the difference is between his previous inhaler and this one as the branding is the same. What is the most appropriate advice?
A) The Fostair 100/6 NEXTHaler is a preventative therapy, and the salbutamol should be used as a reliever therapy. The only difference is that the NEXTHaler is more environmentally friendly
B) The Fostair 100/6 NEXThaler is a reliever therapy, and the salbutamol should be used as a preventative therapy
C) The Fostair 100/6 NEXTHaler is to be used as both a preventative therapy and reliever therapy. The patient no longer needs his salbutamol inhaler, so this can be thrown away
D) The Fostair 100/6 NEXTHaler is to be used as both a preventative therapy and reliever therapy. The patient no longer needs to use his salbutamol as a reliever but should keep it in case he does not tolerate MART therapy
E) The Fostair 100/6 NEXTHaler is to be used as preventative therapy, and the salbutamol should be used as a reliever therapy. As Fostair 100/6 NEXTHaler still contains inhaled corticosteroids, a spacer should be used
D
RATIONALE: MAINTENANCE AND RELIEVER THERAPY (MART) IS AN
ASTHMA TREATMENT PLAN WHERE YOU USE ONE COMBINATION
INHALER INSTEAD OF TWO SEPARATE PREVENTER AND RELIEVER
INHALERS. THE PURPOSE IS THAT THE LONG ACTING BRONCHODILATOR
IS ALSO FAST IN ITS TIME TO ACTION, SO CAN BE USED AS A
RELIEVER AND PREVENTER. IN THIS CASE, THERE IS NO GUARANTEE
THAT THE PATIENT WILL TOLERATE MART THERAPY AS A NEXTHALER
IS A DRY POWDER INHALER, SO ADVISING TO KEEP THE SALBUTAMOL
TO HAND IS THE MOST PRAGMATIC APPROACH.
A patient with a history of frequent respiratory infections is prescribed a prophylactic antibiotic with activity against atypical pathogens. Which class of antibiotics is commonly used for this purpose?
A) Aminoglycosides
B) Cephalosporins
C) Macrolides
D) Penicillins
E) Quinolones
C
RATIONALE: MACROLIDES, SUCH AS AZITHROMYCIN, ARE USED TO
COVER AGAINST ATYPICAL AGENTS PROPHYLACTICALLY.
AMINOGLYCOSIDES HAVE POOR ORAL BIOAVAILABILITY, SO THIS ISN’T
CORRECT. CEPHALOSPORINS AND PENICILLINS GENERALLY GIVE GRAM
POSITIVE COVER. QUINOLONOES GIVE BROAD GRAM POSITIVE AND
GRAM NEGATIVE COVER, BUT ARE SELDOM USED PROPHYLACTICALLY.
Which of the following medications is a first-line treatment for smoking cessation by reducing nicotine cravings and withdrawal symptoms?
A) Bupropion
B) Varenicline
C) Nicotine replacement therapy
D) Nortriptyline
E) Clonidine
C
RATIONALE: NICOTINE REPLACEMENT THERAPY, AS WELL A
OTHER NON-PHARMACOLOGICAL APPROACHES ARE
CONSIDERED FIRST LINE FOR SMOKING CESSASTION.
A patient has been started on a Fostair NEXTHaler, a dry powdered inhaler. The patient asks you, as the pharmacist independent prescriber running the asthma and COPD clinic, to explain how to use the inhaler. What is the most appropriate inhale technique for a dry powder inhaler?
A) Fast and deep
B) Fast and deep with a spacer
C) Shake the inhaler to suspend the powder, then slow and steady after pressing the canister
D) Slow and steady without the use of a spacer
E) Slow and steady with a spacer
A
RATIONALE: DRY POWDER INHALERS REQUIRE FAST AND
DEEP BREATHING; FAST TO DISTURB THE POWDER BED, AND
DEEP TO ALLOW FOR ADEQUATE DEPOSITION OF THE
PARTICLES INTO THE LUNGS. A SPACER WOULD NOT BE
APPROPRIATE WITH A DRY POWDER.
D
RATIONALE: DOXYCYCLINE OR AMOXICILLIN ARE YOUR FIRST
LINE OPTIONS IN INFECTIVE EXACERBATIONS OF COPD. IN
PENICILLIN ALLERGIES, DOXYCYCLINE IS PREFERRED.
