Resp

Question 1

When has or is the peak of asbestos-related diseases due or did present?

Answer 1

Over the 5-10 years (I.e., around 2019-2024), due to the long latent period between asbestos exposure and disease.Asbestos use was banned in the 1980’s but many people worked with it up until then.

Question 2

What nations still produce and use lots of asbestos?

Answer 2

Brazil, Russia, China, Kazakhstan. So important to know about asbestos related disease not only for the point of view of uk workers who used to work with it, but migrants from countries that still use it.

Question 3

What are the two types of asbestos? How widely used are/were they?

Answer 3

White - chrysotile, accounts for more than 95% of use worldwide! serpentine minerals! curly long woven fibres.Blue/brown - corcoidolite, amosite, and others - straighter, brittle, less malleable.

Question 4

What are the useful properties of asbestos which meant it was and still is used so widely?

Answer 4

Heat, fire, and chemical resistance.Electrical and sound insulation.Medium tensile strength.Therefore very valuable in industry, especially in building and construction.

Question 5

What are the four grades of asbestos-related lung disease?

Answer 5

1) benign disease (pleural plaques, diffuse pleural thickening, benign pleural effusion).2) asbestososis (a type of interstitial lung disease).3) lung cancer.4) malignant mesothelioma (cancer of the pleural layer, very dangerous).

Question 6

What is the epidemiology of asbestos-related disease? (Three points)

Answer 6

As mentioned previously, peak onset between now and 2024.Male:female ratio of 4:1 (due to exposure; more men worked with asbestos than women).It is rare under the age of 40 (due to long latent period).

Question 7

What is the pathophysiology of asbestos related disease? What properties of asbestos molecules make it difficult for the lungs to clear? (Name 3).

Answer 7

The fibres become airborne, are inhaled, and are trapped inside the lungs. They are classified as carcinogens. Mucocilliary clearance gets rid of some, but not all of these fibres, because of their special properties:1) they are long, therefore cannot be completely enclosed by macrophages, and are not effectively cleared.2) they are thin - this mean they can travel deep into the respiratory network, beyond they point where mucucilliary clearance occurs.3) biopersistance - they are not broken down, they accumulate over time.

Question 8

What are the risk factors for developing asbestos related disease? (name 3).

Answer 8

1) the dose of asbestos that an individual is exposed to; the quantity and duration of that exposure.2) type and size of fibre; it is thought that blue or brown asbestos (amphibole sub types) has a greater propensity for causing mesothelioma than the white (chrysotile). This is due to the structure of the molecule.3) personal factors: smoking, pre-existing lung disease, sex, age, etc.

Question 9

Is smoking a risk factor for developing mesothelioma?

Answer 9

A sneaky question!Smoking on it’s own is NOT a risk factor for developing mesothelioma.BUT if you are exposed to asbestos AND you are a smoker, you have around twice the risk of developing mesothelioma. Also this population has 50-90% increased risk of developing asbestos-related lung cancer.Weird, huh?

Question 10

Apart from people who directly handle asbestos, who else is at risk of asbestos exposure. (Name two).

Answer 10

The families of the people exposed - they are exposed to, e.g., asbestos on the clothes of the worker.Also people who live close to sites where asbestos is manufactured, or where asbestos-containing products are manufactured.

Question 11

What occupation carries the greatest risk of asbestos exposure?

Answer 11

Mining asbestos!Fortunately, the UK never had asbestos mines…but other countries did (and do) and migration means we may see the results of this.

Question 12

What occupations are at-risk for asbestos exposure? (There are seven named here; name 4).

Answer 12

1) miner of asbestos (not in the uk).
2) shipyard workers. (E.g., insulation of boiler pipes, incinerators, pipes. Fibres build up in poorly ventilated areas of the ship).
3) demolition. (Disturbed fibres become airborne).
4) car manufacturing. (Manufacture or repair of breaks and clutch pads)
5) construction. (Electricians, cement production, insulators, pipe-fitters, steel workers, plumbers, roofers, welders).
6) railway workers. (Especially those involved in carriage insulation).
7) manufacturing. (Specifically manufacturing of asbestos containing products for home and industry).

Question 13

Ini addiction to occupational exposure, and the families of these workers, and the people who live near sites of asbestos manufacture, who else might be exposed?

Answer 13

Anyone who tampers with products that contain asbestos!Any building built prior to 1980 probably has asbestos in it - which is ok as long as it is not disturbed.Self employed plumbers, electricians, builders and carpenters of today may unwittingly expose themselves.Also, DIY enthusiasts may do the same.

Question 14

Who should remove asbestos?

Answer 14

By a licensed contractor, as set out by the UK’s HSE. But this is NOT often done!

Question 15

Who should a GP be most suspicious of asbestos related disease in? What should they do?

Answer 15

Middle aged or elderly men, with a history of asbestos exposure, presenting with respiratory symptoms, especially SOBOE.GP’s should: take a thorough occupational and social history, clinical history, full exposure to asbestos history (if known, the type of asbestos exposed to, and the duration of that exposure), full clinical examination.

Question 16

According to the 2005 NICE guidelines, what should be done with a patient who has a history of asbestos exposure, presenting with SOB, chest pain, unexplained systemic symptoms, or clinical suspicion of cancer?

Answer 16

They should be referred urgently (2WW) to the lung physicians!Duh!

Question 17

Other than an CXR which can be order in primary care, what secondary care investigations might be useful if asbestos related disease is suspected?

Answer 17

Lung function testing.High resolution CT scan (v sensitive for detecting early fibrosis and pleural plaques).

Question 18

Who should you tell to stop smoking?

Answer 18

Everybody, of course!But anyone with a history of asbestos exposure should be told twice, because they have double the risk of lung cancer and mesothelioma.

Question 19

Who should be offered the annual influenza and pneumococcal vaccinations?

Answer 19

Those who have been diagnosed with asbestososis, mesothelioma, or lung cancer.
COPD patients.

Question 20

What might be the clinical presentation of someone with benign asbestos related disease?

Answer 20

SOB, chest pain.CXR would show pleural plaques (usually asymptomatic) and diffuse pleural thickening.

Question 21

What might be the presenting symptoms of asbestososis?

Answer 21

SOBOE, dry cough; later, finger clubbing, cor pulmonale.

Question 22

What might be the presenting features of asbestos related lung cancer?

Answer 22

Usually none at first! Occasional dry cough.Advanced stage: haemoptysis, cough, loss of weight, chest pain, fatigue, SOB, pleural effusion.

Question 23

What might be the presenting symptoms of mesothelioma?

Answer 23

Usually none at first; sometimes some chest pain and SOB.Advanced disease: SOB, severe and progressive chest pain, pleuritic chest pain, constitutional symptoms such as loss of weight and fatigue.

Question 24

What is the most common response to exposure to asbestos? What is the latent period? What does this pathology represent? What symptoms might thee patients have, what is there prognosis, and how should they be treated?

Answer 24

Pleural plaques, which usually occur 20-40 years after exposure.They are usually asymptomatic. They are areas of fibrous thinking that usually become calcified over time, usually affecting the parietal pleura (occasionally the visceral pleura affected too).They do not generally progress to anything nasty - they are benign - and it is important to tell patients this; the treatment is reassurance and monitoring in primary care.However, it would be prudent to advise these patients to report any red flag signs, e.g., haemoptysis, persistent chest pain, or SOB should they develop.

Question 25

What is asbestos related diffuse pleural thickening?

Answer 25

This refers to fibrosis of the visceral pleura as well as loss of pleural space.On a CXR, usually appears as unilateral or bilateral diffuse pleural thickening, with blunting of costophrenic angles.

Question 26

What often precedes the development of diffuse pleural thickening (DPT) and can facilitate disease progression?

Answer 26

Benign asbestos related pleural effusion.

Question 27

What do benign asbestos related pleural effusion and benign diffuse pleural thickening have in common?

Answer 27

They are both diseases of exclusion - other causes must be ruled out first, e.g., TB, malignancy; or mesothelioma in the case of pleural thickening.Some patients with a benign asbestos related pleural effusion will need a pleuritic tap if it is large or symptomatic.

Question 28

When doe benign asbestos related pleural effusion present? What type of effusions are they?

Answer 28

The lag time is short compared to other forms of asbestos related disease - as short as ten years.They are often small exudative effusions, and may regress spontaneously.They may also herald the onset of benign diffuse pleural thickening.

Question 29

What investigations are required if benign asbestos-related diffuse pleural thickening is suspected?

Answer 29

Intitially, HRCT is the imagining of choice - it is more sensitive than CXR at assessing DPT and it's extent.However, as asbestos related DPT is a diagnosis of exclusion, other investigations are then usually performed, possibly including MRI, positron omission tomography, and pleural biopsy (to exclude malignant mesothelioma).

Question 30

Diffuse pleural thickening (DPT) has many causes other than asbestos exposure, hence asbestos related DPT being a diagnosis of exlusion.What can cause DPT? (Name 5)

Answer 30

1) asbestos exposure2) previous thoracotomy or pleurodesis3) TB4) bacterial infection5) connective tissue disease6) haemothorax

Question 31

What would be the spirometry of someone with diffuse pleural thickening?

Answer 31

A restrictive ventilators defect.

Question 32

What treatment is there for diffuse pleural thickening?

Answer 32

Not much - it is generally just supportive. Occasionally, non-invasive ventilation is used when type 2 respiratory failure develops.

Question 33

What is the definition of asbestososis? What is it the most common of?

Answer 33

Bilateral pulmonary fibrosis secondary to asbestos inhalation. Usually there is a lag time of at least 20 years.It is the most common of all the pneumoconiosis diseases and has similar characteristics to interstitial lung fibrosis.

Question 34

What is the pathogenesis of asbestososis?

Answer 34

Asbestos is fibrogenic to the lungs. Asbestos deposits in the lung causes collagen deposits in the alveolar epithelium and surrounding tissues.

Question 35

What is the most common presenting feature of asbestosis?

Answer 35

SOBOE and non productive cough.Advanced features include chest tightness and features related to pulmonary hypertension and cor pulmonale.

Question 36

What examination findings might there be to be found on someone with asbestososis?

Answer 36

Two thirds of patients have fine bi-basal end-inspiritory crackles.Finger clubbing and reduced chest expansion may also be seen.Note that radiographic or pulmonary function testing suggestive of interstitial lung disease often precedes the development of clinical signs.

Question 37

As with all forms of interstitial fibrosis, what will be found on lung function testing in asbestososis? How about chest radiography/HRCT findings? And pulse oximetry? If this isn't sufficient for a diagnosis, what can be done, and what would be seen?

Answer 37

Lung function testing would show restrictive pattern with reduction in total lung capacity, vital capacity, and small airway flow rates.CXR will show reticulonodular shadowing in the lower zones.HRCT will show interstitial infiltrates.Pulse oximetry may give evidence of desaturation on exertion.If this is not enough, or if diagnosis is in doubt, then a tissue sample can be taken - pathology will show fibrosis and presence of ferringous bodies (asbestos fibres with a ferritin coating) in the interstitium.

Question 38

What are the treatment options for asbestososis?

Answer 38

Unfortunately, asbestososis does not respond to convention treatments for interstitial lung diseases - so no role for steroids or immunosuppressants.So management is initially generally supportive.Supplementary oxygen should be offered for those with those at rest or on exercise.Respiratory physiotherapy also plays an important role, as does palliation in the latter stages.

Question 39

What type of lung cancer does asbestos exposure increase the risk of?

Answer 39

All types!Though note (again!) that smoking + asbestos exposure increases the risk more than would be expected - about twice as much!Asbestos related small cell and non-small cell lung cancers are clinically identical to other tumours of these types.

Question 40

Where does mesothelioma arise?

Answer 40

Typically in the pulmonary pleura (80%).BUT can also occur peritoneum, the pericardium, and even the tunica vaginalis of the testes!It develops from the mesothelial cells found in these places.

Question 41

Mesothelioma usually arises secondary to asbestos exposure, with an average lag time of 32 years. But what else can cause it?

Answer 41

Exposure to other fibrous silicate materials, e.g., erionite. Irradiation. Smoking does not (unless also exposed to asbestos - in which case the risk is doubled!)

Question 42

What are the typical presenting symptoms of malignant mesothelioma?

Answer 42

Dyspnoea (often secondary to pleural effusion or pleural thickening).Chest pain (often described as progressive and dull).Systemic features such as weight loss and fatigue.If peritoneal mesothelioma, then may get abdominal pain, ascites, or features of bowel obstruction.

Question 43

Does mesothelioma typically metastasise? If so where to?

Answer 43

No, it is not common to.But when it does, typical sites include bone, liver, and lymphatics.

Question 44

What radiographical features might alert you to the possibility of mesothelioma in a patient with a history of asbestos exposure?What is required to confirm the diagnosis? How is this done?

Answer 44

Pleural thickenings, chest wall masses, or effusion notes on CXR or HRCT.The diagnosis is confirmed by histological and/or cytological examination (important if money / reparations is an issue!!).Pleural aspiration or US-guided pleural biopsy are the usual methods of obtaining a sample; if the facilities exist, then thoracoscopy can be employed to drain the pleural fluid, get a biopsy of the pleura, and also carry out a pleurodesis.

Question 45

What system is used to stage malignant mesothelioma?

Answer 45

TNM staging.

Question 46

What is the prognosis of malignant mesothelioma?

Answer 46

Extremely poor. Even with treatment, life expectancy is 8-14 months from time of diagnosis. Partly this is due to late presentation.

Question 47

What are the treatments used for mesothelioma?

Answer 47

Chemotherapy, radiotherapy, or surgery (pneumonectomy).But these are usually palliative measures, and do little to improve survival times.Treatment is therefore often symptomatic and palliative.

Question 48

Does asbestos exposure ever result on disease in extra-pulmonary sites?

Answer 48

There is some evidence that it can cause peritoneal mesothelioma, autoimmune disease, and reproductive malignancies (ovarian cancer and testicular malignant mesothelioma).The hypothesis is that swallowing fibres of e.g., chrysotile from occupational exposure or swallowing water from pipes lined with asbestos can lead to this. But all studies involved in this have been small and low-powered.

Question 49

In what part of the country do most asbestos support groups reside and why?

Answer 49

The north of England and Scotland as this is where asbestos use was highest.

Question 50

In general, what is the role of the GP in supporting a patient diagnosed with an asbestos-related condition?

Answer 50

To give information on the nature of the disease and the extent of lung damage.To give an idea of prognosis.To sometimes give treatment (though this is often secondary care).Guidance on financial compensation.Sign posting the patient to appropriate support- e.g., assessment in a dedicated occupational respiratory clinic by OH physicians working with respiratory physicians.

Question 51

Is there a single website that lists all the mesothelioma support groups?

Answer 51

Mesothelioma UK.Provides details of all support groups in the UK.Also lots of specialist mesothelioma information.

Question 52

What compensations exist in the UK for those affected by asbestos related disease? (5 facts, name 4).

Answer 52

-Since 2007, those in England and Wales cannot claim for benign pleural plaques.-IIDB : weekly allowance payed by department of work and pensions to those who contracted an industrial disease during their employment.-The pneumoconiosis etc (workers compensation) act 1979: a lump sum payment payable to those who cannot claim from former employers because those employers are no longer trading. Can be claimed by dependants after death of patient.-Diffuse Mesothelioma Payment: since 2008, lump sum payable to those diagnosed with mesothelioma; may be claimed by dependants of the dead.-A War Disablement Pension: may be claimed if disease arises from exposure during service in the armed forces in the UK.

Question 53

What percentage of adults in the UK smoke?

Answer 53

About 20%! And that has stayed stable for the last 5 years.

Question 54

How much % of the adult population in the UK is affected by COPD?

Answer 54

About 6%, though many remain undiagnosed.It is estimated that COPD will become the worlds 3rd largest cause of death by 2020.

Question 55

Very broadly, how is the multidisciplinary management of COPD divided? (Name 3, there are 4).

Answer 55

1) smoking ceasation.2) pulmonary rehabilitation.3) other multidisciplinary interventions.4) medical management including including inhaled and oral pharmacotherapies and oxygen therapy.

Question 56

When is management of COPD seen as being successful?

Answer 56

If there is a reduction in exacerbations of the disease.

Question 57

What is the most beneficial management step for COPD patient? What evidence? How can this be achieved?

Answer 57

Stopping smoking. After 5 years, rate of FEV1 decline and related symptom frequency was significantly reduced in patients who stopped smoking.Options include self help materials, quit lines (e.g., NHS stop smoking sevice), group behavioural counselling, brief interventions by healthcare professionals working at the GP practice, and pharmacotherapies.

Question 58

What pharmacological therapies exist to help quit smoking? Should they be used together? What should be done before/when starting them?

Answer 58

Current pharmacotherapies include nicotine replacement therapy, varenicline, and bupropion.They should not be used together.Choice of pharmacotherapy should be discussed with patient, previous ones used, interactions should be discussed.A quit date should be agreed on and pharmacotherapy started on the same day. Pharmacotherapies are best used when used in combination with behavioural therapies.

Question 59

Describe the transtheoretocal model of health behaviour change? (As used in e.g., quitting smoking and addiction?)

Answer 59

Addiction --> pre-contemplation --> contemplation --> preparation Preparation can either lead to action or relapse.Relapse --> addiction.Action can either lead to maintenance or relapse.Maintenance seems to lead to relapse, but it seems to me that it might result in itself - maintenance of non-addiction.

Question 60

What is the system adopted by NICE used to grade treatment of COPD?

Answer 60

GOLD grading system/criteria. Grades disease severity and guides management. Invented by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

Question 61

What does the GOLD criteria for COPD measure to grade which stage of disease progression has been reached? (3 things).

Answer 61

1) FEV1/FVC.2) FEV1%3) Subjective and objective patient experience - essentially dyspnoea, number of exacerbations, exercise tolerance.

Question 62

How many stages of GOLD are there? What are they known as? What defines them?

Answer 62

There are 4 stages:1) mild COPD: FEV1/FVC less than 70%; FEV1 equal to or greater than 80% predicted; no or minimal symptoms.2) moderate COPD: FEV1/FVC less than 70%; FEV1 50-79% predicted; mild symptoms (e.g., dyspnoea on significant exertion)3) severe COPD: FEV1/FVC less than 70%; FEV1 30-49% predicted; increasing symptoms (e.g., recurrent exacerbations, poor exercise tolerance).4) very severe COPD: FEV1/FVC less than 70%; FEV1 less than 30% predicted or less than 50% plus respiratory failure; serve symptoms, e.g., minimal exercise tolerance, dyspnoea at rest.

Question 63

What medical treatment should be used at GOLD stage 1 for COPD? What would indicate progression to stage two is possible?

Answer 63

SABA or SAMA to be used for symptom relief. If used more than 4 times a day, regular exacerbations, or continued symptoms, then consider going to stage 2.

Question 64

What medical treatment should be used at GOLD stage 2 for COPD? What would indicate progression to stage three is possible?

Answer 64

Addition of LAMA or LABA. Continue SABA or SAMA.If continued symptoms such as breathlessness or recurrent exacerbations then consider stage three.

Question 65

What medical treatment should be used at GOLD stage 3 for COPD? What would indicate progression to stage four is possible?

Answer 65

Continue LAMA; consider inhaled corticosteroid and/or LABA combined inhaler.If continued symptoms such as breathlessness or recurrent exacerbations then consider stage four.

Question 66

What medical treatment should be used at GOLD stage 4 for COPD?

Answer 66

Continue LAMA; corticosteroid and/or LABA combination inhaler; consider other pharmacological interventions.

Question 67

What are the three broad categories of medical management for COPD patients?

Answer 67

1) inhaled bronchodilators etc. 2) oral theophylline or mucolytics. 3) oxygen

Question 68

What are the advantages of short acting bronchodilators in COPD? What are examples of such? How long do they take to take effect, and how often can they be given?

Answer 68

The advantage is a rapid onset of action.Short acting beta agonists (SABA) e.g., salbutamol, terbutaline act on bronchial smooth muscle wall to stimulate bronchodilation, reduce gas trapping and the work of breathing. They take 5 minutes to take effect and can be given every 2-4 hours.Short acting muscarinic antagonists antagonise cholinergic nerves in the bronchoconstrictor pathway to allow smooth muscle relaxation. This is effective as the airway resting tone in COPD is often increased. SAMA work in 15 minutes and can be used every 6 hours. Ipratropium bromide is the most widely used.

Question 69

What are the indications for referral for assessment for oxygen therapy in COPD patients?

Answer 69

1) Central cyanosis. 2) Raised JVP (indicative of right heart failure). 3) Peripheral oedema. 4) FVC1 less than 30%. 5) Sats less than 92% on room air at rest. 6) Polycythaemia.

Question 70

What is the only long acting muscarinic antagonist? How often is it taken and how long does it last? What effect does it have? What stage in the GOLD framework is it used?

Answer 70

Tiotropium bromide. It is taken once a day, works for 36 hours, and slows rate of FEV1 decline, and reduces wheezing, dyspnoea, exacerbation rates, and the amount of rescue medication needed. It should NOT be taken with its short acting alternative. It is used in stage 2 GOLD upwards.

Question 71

What is the role of oral corticosteroids in COPD? Are they used long term?

Answer 71

They have a role in managing exacerbations, but not really in long term maintenance. Despite this 5% of COPD patients are on low dose oral corticosteroids long term. If needed, keep the dose as low as possible and consider protection from side effects (e.g., bone protection, gastric irritation). Side effects include osteoporosis, gastritis, adrenal suppression, and hypertension.

Question 72

What is the mechanism of action of theophylline in COPD? (5)

Answer 72

It is unclear! Thought to act at multiple sites including: 1) relaxing airway smooth muscle. 2) Increasing diaphragmatic strength. 3) Increase mucocilliary clearance. 4) Improve the response to steroid therapy. 5) May also increase cardiac output to further enhance cardiorespiritory function.

Question 73

When giving theophylline, what should have been tried first? What side effects might indicate a need to cease therapy (7!). When should it absolutely not be given?

Answer 73

When starting it, patients should have already been tried on LABA + SABA or LAMA. Side effects that may indicate a need to discontinue include: 1) Seizures. 2) Diarrhoea. 3) Arrhythmias. 4) Sleeplessness. 5) Allergic reaction. 6) Vomiting, 7) Confusion. Should absolutely NOT be given if any form of liver dysfunction.

Question 74

In a patient given theophylline, what measurement is needed and why? What drugs might interact with theophylline? What route is it given by?

Answer 74

There is a need to regularly measure plasma levels, as they may reach toxic levels. It can interact with many thanks that change the metabolism and therefore concentration, but most notably macrocodes and fluroquinolone (which is sometimes given during exacerbations); also smoking messes it up! There is a slow release oral preparation, but in hospital it tends to be given IV.

Question 75

What are the long acting beta agonists? How long do they last? What GOLD stage should they be introduced in COPD? Should they be used with SABA's?

Answer 75

They can be used with their short acting beta-agonist versions (unlike LAMA's). Used in GOLD 2 and above. Examples include formoterol and salmeterol. They last around 12 hours (while LAMA's last around 36).

Question 76

What advantages of LABA's been shown to have?

Answer 76

They reduce night-time waking, dyspnoea, exercise-induced dyspnoea, and need for rescue agents.

Question 77

When should inhaled corticosteroids be used in COPD?

Answer 77

GOLD 3 or 4 if symptoms are not adequately controlled by bronchodilators. Also might be used if there is thought to be a reversible (asthmatic) component to the COPD in the patient in question. This might be the case if they have relatively mild disease by FEV1 criteria, but still have significant clinical symptoms.

Question 78

What stand alone corticosteroid inhalers are licensed for COPD? What are the potential side effects of inhaled corticosteroids? When should the use of inhaled corticosteroids be reviewed?

Answer 78

There are NO stand alone inhaled corticosteroids licensed for COPD! Preparations are mixtures of corticosteroid and LABA. Side effects include increased risk of non-fatal pneumonia. The use of inhaled corticosteroids should be reviewed if they have no effect on the number of exacerbations, lung function, or symptoms.

Question 79

Is there a role for long term antibiotics in COPD? If not, why not? If so, which one(s) and why? And when should they be started? What sub-group of patients with a co-morbidity might it be of especial use in, and how could they be identified?

Answer 79

Generally, there is no role for long term abx. It will select out resistant organisms and there is the risk of side effects. That said, there is research that azithromicin might be of benefit, as it might also have an anti-inflammatory action. If started, it should be done by secondary care, either after an inpatient admission or an outpatient appointment. It may be of especial value in patients who also have bronchiectasis (these can be detected by HRCT, also high sputum volume production in the morning suggests bronchiectasis).

Question 80

What is the role of mucolytics in COPD? What mucolytics are there? Why might it not be a good idea to use one of them?

Answer 80

In theory, they increase the ability to expectorate mucus. It may have a role in patients with a chronic productive cough, but has no role in preventing exacerbations. Carbocystine orally is most commonly used. Nebulised hypertonic saline or water is also used, but this is controversial and perhaps should not be, as it can introduce infection and cause acute bronchospasm. If there is no clear symptomatic improvement over time, then the mucolytic should be stopped.

Question 81

Are there other, non-conventional oral therapies for COPD?

Answer 81

1) Antioxidants have been tried, but no clear benefit. 2) Monteleukast is NOT for COPD only asthma. 3) PDE-4 inhibitors show some promise, perhaps by increasing smooth muscle relaxation and by reducing inflammation, but it is not approved for routine use in GP.

Question 82

How can home oxygen therapy help COPD patients?

Answer 82

1) Symptomatically/improving quality of life - less dyspnoea on execration or rest. 2) Increase long term survival by reducing cardiac strain and improving pulmonary haemodynamics.

Question 83

When a specialist assessment for HOOF for COPD patients is carried out (i.e., in secondary care by specialists) what will this involve?

Answer 83

Two separate ABG's at least 3 weeks apart. HOOF is indicated if Pa02 is less than 7.3 of less than 8 with polycythemaea, pulmonary hypertension, or nocturnal 02 sats less than 90% for more than one third of the night.

Question 84

What is the most notable side effect of inappropriate HOOF Rx for COPD patients? What must they be advised never to do?

Answer 84

The main adverse affect is respiratory depression. Patients must be warned NEVER to smoke near oxygen cylinders.

Question 85

How many hours a day should HOOF be used by COPD patients for it to be effective? How is it delivered?

Answer 85

Should be given for at least 15 hours a day. Can be given via a face mask or nasal cannulas;there may be provision of ambulatory oxygen cylinders so the patient can leave the house.

Question 86

What if a COPD patient on HOOF becomes significantly hypercapnic or acidotic on oxygen?

Answer 86

They should be assessed for home non-invasive ventilation. This is especially true if they have co-morbidities such as sleep apnoea, or recurrent infections causing type 2 respiratory failure.

Question 87

What vaccinations should COPD patients be offered?

Answer 87

Annual influenza vaccination. | Pneumococcal vaccination.

Question 88

Which COPD patients should be offered pulmonary rehabilitation?

Answer 88

1) Patients who consider themselves functionally disabled by COPD. 2) Patients who are GOLD stage 1, 2, or 3 3) A score of 3 or more on the MRC dyspnoea scale.

Question 89

Who leads pulmonary rehabilitation programs? What is the benefit? How long does the benefit last?

Answer 89

Usually respiratory physiotherapists and nurse specialists. Benefits last for 12 months, and can be repeated if the patient starts to deteriorate. They improve quality of life and decrease utilisation of healthcare resources.

Question 90

Why is good nutrition important in COPD?

Answer 90

patients with COPD are often undernourished due to: 1) Difficulties in mastication while dyspnoeic 2) Increased energy demands of laboured breathing. There is a correlation between being undernourished and having more exacerbations, decreased muscle strength, decreased immunity, and overall mortality. Try to measure BMI at review and stress importance of energy (especially protein), consider dietician referral.

Question 91

What is the impact of psychological factors in COPD?

Answer 91

Like anxiety and depression often result. As a GP you can attempt to manage this with regular anti-depressant/anti-anxiety drugs, and various therapeutic interventions. This may not be enough, especially for those with dyspnoea in the absence of hypoxia, in which case referral to clinical psychologist or psychiatrist may be helpful. The last resort should be starting something with potentially dangerous side effects - notably opioids and benzodiazepines - due to the risk of respiratory depression and other side effects. Respiratory physicians and palliative care involvement may also give advice on prescription of these drugs.

Question 92

Is there a role for palliative care in COPD patients? If so, what things might be discussed?

Answer 92

Yes! As the disease progresses and as GOLD 4 is reached, input from palliative specialisists may be useful. Things that can be discussed might include: 1) Advanced directives. 2) Ceiling of care 3) Ventilators in the end of life setting 4) Potential use of opioids and benzo's Patients should be encouraged to have friends/family present as required during these meetings.

Question 93

Has Hospital at Home (HAH) been shown to reduce admissions in COPD patients?

Answer 93

No, unfortunately they have not been shown to reduce admissions or overall mortality. However... ...they have been shown to dramatically improve the patient's quality of life.

Question 94

Are people with COPD entitled to benefits? Where can advice be sought?

Answer 94

Maybe, especially if their illness causes significant disability and they are under 65. See department of work and pensions.

Question 95

For patients with respiratory disease, there are prognostic indicators which indicate end of life is near. Two or more of these mean death is approaching. There are 7 - name them!

Answer 95

1) Signs and symptoms of right heart failure. 2) Disease assessed to be severe. 3) Grade 4 or 5 MRC dyspnoea scale. 4) For COPD, use of over 6 weeks of systemic corticosteroids over a 6 month period. 5) Recurrent hospital admissions. 6) Fulfil the criteria for long term oxygen therapy. 7) A combination of factors including depression, anorexia, and recurrent infections.

Question 96

How often should patients with COPD be reviewed in primary care, and by whom?

Answer 96

At least once a year for GOLD 1 or 2. At least twice a year for GOLD 3 or 4. Should be carried out by a doctor or a specialist nurse.

Question 97

When COPD patients are reviewed in primary care, what should be asked/done? (There are 12! 7 would be good...)

Answer 97

1) Docu,net smoking status. 2) Patient experience of symptom control. 3) Review complications, including admissions, and need for either steroid or antibiotic therapy for current or emergency use. 4) Side effects of regularly prescribed meds. 5) Assessment of inhaler technique and ? does this patient need a spacer? 6) Consider referral to another member of the multidisciplinary team. 7) Consider enrolment in pulmonary rehab program. 8) Oxygen sats. 9) FEV1 Vs predicted. 10) FVC 11) BMI 12) MRC dyspnoea scale

Question 98

What might prompt referral of a COPD patient to secondary care (if they are not already under secondary care!) (6)

Answer 98

1) Haemoptysis. 2) Unclear diagnosis 3) Rapid decline 4) Early onset (under 40) 5) Bronchiectasis considered 6) If patient is a possible candidate for lung transplant of for lung volume reduction surgery (i.e., patient's who remain breathless despite maximal medical and pulmonary therapy)

Question 99

What are the stages of the medical Research Council dyspnoea scale?

Answer 99

1) Not troubled by breathlessness, except on strenuous exercise. 2) Short of breath when hurrying or walking up a slight hill. 3) Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace. 4) Stops for breath when walks about 100 metres or after a few minutes on level ground. 5) too breathless to leave the house, or breathless when dressing or undressing.

Question 100

According to GOLD criteria, what is absolutely required to make a diagnosis of COPD?

Answer 100

Although there are of course many clinical features that would suggest a diagnosis of COPD, GOLD say that you can only make the diagnosis after spirometry!

Question 101

How many people in the UK do NICE think are probably living with undiagnosed COPD?

Answer 101

Two million. | Wow.

Question 102

When a patient with COPD is admitted to hospital, what is the chance of them being readmitted, and within what time frame?

Answer 102

There is a 33% chance of readmission with the media time to readmission of 38 days.

Question 103

How do the British Thoracic Society define pulmonary rehabilitation?

Answer 103

"An interdisciplinary program of care for patients with chronic respiratory impairment, that is individually tailored and designed to optimise each patients physical and social autonomy. Programs comprise individualised exercise programs and education.

Question 104

What is the backbone of pulmonary education, I.e., what is the main thing that it comprises?

Answer 104

Short outpatient-based programmes, usually run by a specialist nurse, that centres on aerobic exercise and on education.

Question 105

What are the general principles of pulmonary rehabilitation? (5)

Answer 105

1) The goals of rehabilitation are to reduce the symptoms, disability, and handicap, and to improve functional independence in people with lung disease. 2) It is assumed that optimal medical management has been achieved or continues alongside the rehab process. 3) The rehab programme incorporates physical training, disease education, nutritional, psychological, social and behavioural interventions. 4) Rehabilitation is provided by a multidisciplinary team, with involvement of the patient's family, and attention to individual needs. 5) The outcome of the rehab for individuals (and the way the programme is run itself!) should be continually observed, with the appropriate measure of disability, handicap, and impairment being monitored - I.e., is it working?

Question 106

In pulmonary rehabilitation, how many sessions a week are recommended?

Answer 106

A minimum of twice a week supervised sessions, with the possibility of a third unsupervised session of prescribed exercises.

Question 107

In pulmonary rehabilitation, how many sessions should be offered/attended?

Answer 107

Although there may be gains from shorter programs those of 6-12 weeks duration demonstrate the most significant benefit, with attendance at a minimum of 12 supervised sessions. It is sometimes possible to run the sessions in the patient's home, but practical considerations must be made, e.g., getting the exercise equipment there, staff availability to travel out to a remote location, etc.

Question 108

Exercise is the main focus of pulmonary rehabilitation programs; what sort of exercise is advised? And what is the aim?

Answer 108

The aim is to increase capacity and to reduce dyspnoea during exercise. The form of the exercise is usually a combination of endurance/aerobic training, alongside strength/resistance work, delivered in a way that empowers the patient to continue effective exercise once the supervised sessions have ended. Although this is a generic form of exercise, it is tailored to the individual - e.g., the intensity of exercise and the targets set should be different from patient to patient.

Question 109

Endurance training is at the heart of pulmonary rehabilitation - what form does this usually take?

Answer 109

It is most usual to consist of walking and/or cycling for 20-30 minutes. This is guided by intensity, duration, and frequency. One or two of these variables is usually fixed, and the third increased in an effort to improve function and meet the set target. So for example, the duration might be set at a fixed thirty minutes; the intensity is then gradually increased to meet the target.

Question 110

How do you measure the intensity of an exercise in pulmonary rehabilitation?

Answer 110

Typical measures include heart rate, treadmill speed, resistance on a exercise bike, etc.