Resp Med

Question 1

Give three triggers of asthma

Answer 1

INfection, night time or early morning, exercise, animals, dust, strong emotions, cold/damp

Question 2

When is asthma typically worse?

Answer 2

Diurnal variation - worse at night

Question 3

What are the first-line investigations for asthma?

Answer 3

Fractional exhaled nitric oxide, spirometry with bronchodilator reversibility

Second-line incl keeping a diary of peak flow measurements several times per day

Question 4

How do SABAs work?

Answer 4

Adrenalin acts on the smooth muscles of the airways to cause relaxation. This results in dilatation of the bronchioles and improves the bronchoconstriction present in asthma.

Question 5

Give an example inhaled corticosteroid

Answer 5

Beclometasone

Question 6

What are ICS’s used for?

Answer 6

Maintenance or preventer medications

Question 7

Give an example LABA. When do we use them?

Answer 7

Long-acting beta 2 agonists (LABA), for example salmeterol. These work in the same way as short acting beta 2 agonists but have a much longer action.

Question 8

Give an example LAMA

Answer 8

Tiotropium

Question 9

How do LAMAs work?

Answer 9

These block the acetylcholine receptors. Acetylecholine receptors are stimulated by the parasympathetic nervous system and cause contraction of the bronchial smooth muscles. Blocking these receptors leads to bronchodilation.

Question 10

Give an example leukotriene receptor antagonist. How do they work?

Answer 10

Leukotriene receptor antagonists, for example montelukast. Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction and mucus secretion in the airways. Leukotriene receptor antagonists work by blocking the effects of leukotrienes.

Question 11

How does theophylline work?

Answer 11

This works by relaxing bronchial smooth muscle and reducing inflammation. Unfortunately it has a narrow therapeutic window and can be toxic in excess so monitoring plasma theophylline levels in the blood is required. This is done 5 days after starting treatment and 3 days after each dose changes.

Question 12

What is MART?

Answer 12

Maintenance and Reliever Therapy (MART). This is a combination inhaler containing a low dose inhaled corticosteroid and a fast acting LABA. This replaces all other inhalers and the patient uses this single inhaler both regularly as a “preventer” and also as a “reliever” when they have symptoms.

Question 13

What is a moderate acute asthma attack?

Answer 13

PEFR 50 – 75% predicted

Question 14

What is a severe acute asthma attack?

Answer 14

PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences

Question 15

What is a life-threatening acute asthma attack?

Answer 15

PEFR <33%
Sats <92%
Becoming tired
No wheeze. This occurs when the airways are so tight that there is no air entry at all. This is ominously described as a “silent chest”.
Haemodynamic instability (i.e. shock)

Question 16

What is the first-line treatment for acute moderate asthma attack?

Answer 16

Nebulised beta-2 agonists
Nebulised ipratropium bromide
Steroids - oral pred or IV hydrocortisone: continued for 5 days
? Abx

Question 17

What would an ABG show in acute asthma?

Answer 17

Initially patients will have a respiratory alkalosis as tachypnoea causes a drop in CO2. A normal pCO2 or hypoxia is a concerning sign as it means they are tiring and indicates life threatening asthma. A respiratory acidosis due to high CO2 is a very bad sign in asthma.

Question 18

What electrolyte abnormality can salbutamol cause?

Answer 18

Monitor serum potassium when on salbutamol as it causes potassium to be absorbed from the blood into the cells. Salbutamol also causes tachycardia (fast heart rate).

Question 19

What is the difference between obstructive and restrictive disease?

Answer 19

Obstructive lung disease can be diagnosed when FEV1 is less than 75% of FVC (FEV1:FVC ratio < 75%).

If FEV1 and FVC are equally reduced and FEV1:FVC ratio > 75% this suggests restrictive lung disease.

Question 20

What is the most common type of lung cancer?

Answer 20

Non-small cell lung cancer, most commonly adenocarcinoma (40%) or squamous cell carcinoma (20%)

Small cell lung cancers release neuroendocrine hormones are are responsible for 20% lung cancers)

Question 21

What is Pemberton’s sign?

Answer 21

“Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency.

Seen in SVC obstruction

Question 22

Describe the MRC dyspnoea scale

Answer 22

Grade 1 – Breathless on strenuous exercise
Grade 2 – Breathless on walking up hill
Grade 3 – Breathless that slows walking on the flat
Grade 4 – Stop to catch their breath after walking 100 meters on the flat
Grade 5 – Unable to leave the house due to breathlessness

Question 23

How do we determine the severity of airflow obstruction in COPD?

Answer 23

Stage 1: FEV1 >80% of predicted
Stage 2: FEV1 50-79% of predicted
Stage 3: FEV1 30-49% of predicted
Stage 4: FEV1 <30% of predicted

Question 24

Which vaccines should COPD pts have yearly?

Answer 24

Annual flu and pneumococcal vaccines

Question 25

How do we manage COPD?

Answer 25

Initially beta-2 agonists (salbutamol or terbutaline) or short acting antimuscarinics (ipratropium bromide).

Then LABA + LAMA or LABA + ICS

Question 26

Give an example LABA + LAMA combination inhaler

Answer 26

Anoro Ellipta

Question 27

Give an example LABA + ICS inhaler

Answer 27

Fostair, symbicort and seretide

Question 28

How do we manage COPD exacerbation?

Answer 28

Typical treatment if they are well enough to remain at home:

Prednisolone 30mg once daily for 7-14 days
Regular inhalers or home nebulisers
Antibiotics if there is evidence of infection
In hospital:

Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h)
Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone)
Antibiotics if evidence of infection
Physiotherapy can help clear sputum

Question 29

Give two forms of non-invasive ventilation

Answer 29

BiPAP and CPAP

Question 30

When do we use BiPAP?

Answer 30

Where there is type 2 respiratory failure, typically due to COPD.
Respiratory acidosis (pH < 7.35, PaCO2 >6) despite adequate medical treatment.