Respiratory

Question 1

What are the 3 indicators of nicotine dependence in smokers?

Answer 1

1. First cigarette within 30 minutes of waking 2. Smoking more than 10 cigarettes/day 3. Previous withdrawal symptoms on past quit attempts

Question 2

Suppose a patient comes to you for advice about smoking cessation. She has no features of nictoine dependence on history taking. What is the most appropriate management?

Answer 2

This patient has low nicotine dependence - there is no evidence that pharmacotherapy is beneficial in these patients. The patient should be offered counselling and behavioural techniques

Question 3

Presume you have a patient with COPD who uses rescue salbutamol but who has had 2 exacerbations of COPD in the past 6 months. What is the next most appropriate medication to prescribe?

Answer 3

LAMA (titropium) or LABA (salmeterol) - (or comination with both)

Question 4

What spirometry findings are diagnostic of COPD?

Answer 4

FEV1/FVC ratio <70% and FEV1 <80% predicted after bronchodilator

Question 5

Air travel following spontaneous pneumothorax should be delayed for how long?

Answer 5

6 weeks

Question 6

When are patients who have had traumatic pneumothorax considered safe to fly?

Answer 6

Providing that the lung has fully re-inflated, considered safe at 14 days

Question 7

For patients with asthma that is well controlled, what advice would you give as part of an action plan in regards to worsening asthma control?

Answer 7

Increase the dose of preventer during an acute exacerbation as soon as possible, and also increase the frequency of salbutamol/reliever

Question 8

Give at least 3 examples in which you should prescribe an increase in preventer and/or a course of oral steroids for asthma

Answer 8

Any of: acute symptoms that recur within 3 hours of taking a reliever; increasing difficulty breathing over 1 or more days; night symptoms that interfere with sleep over more than 1 night in a row; peak flow below a predefined level (for those monitoring peak flow daily, level based on personal history of peak flow before and during flares)

Question 9

What are the ‘red flags’ for hospital admission with CAP?

Answer 9

RR 22+, HR greater than 100; SBP <90, acute onset confusion, sats < 92% on room air, multilobar involvement on CXR, lactate more than 2

Question 10

What is the empiric treatment for mild CAP?

Answer 10

Monotherapy with Amoxicillin 1g TDS for 5-7 days

Question 11

Why is Amoxicillin the drug of choice for mild CAP monotherapy?

Answer 11

Because of the increasing rates of strep pneumoniae resistance to tetracyclines and macrolides

Question 12

Describe the general spirometry pattern in COPD

Answer 12

Airflow limitation which is not fully reversible (post bronchodilator FEV1/FVC ratio <0.7 and FEV1 <80% of predicted)

Question 13

How is severity of COPD measured?

Answer 13

Determined based upon symptoms and post-bronchodilator FEV1 (% predicted) values

Question 14

What is the definition of mild COPD?

Answer 14

Post bronchodilator FEV1 60-80% predicted. Few symptoms, breathless on moderate exertion, little/no effect on daily activities, cough and sputum production

Question 15

What is the definition of moderate COPD?

Answer 15

Post bronchodilator FEV1 40-59% predicted. Breathlessness walking on ground level, increasing limitation of daily activities, recurrent chest infections, exacerbations requiring oral steroids and/or antibiotics

Question 16

What is the definition of severe COPD?

Answer 16

Post bronchodilator FEV1 <40% predicted. Breathless on minimal exertion, daily activities severely curtailed, exacerbations of increasing frequency and severity

Question 17

What is the most common type of primary lung cancer?

Answer 17

Adenocarcinoma (non-small cell), which is the most common type of lung cancer diagnosed in all smokers, ex-smokers and non-smokers

Question 18

Which 4 criteria can be used to diagnose asthma in adults?

Answer 18

1. History of variable symptoms (SOB, cough, wheeze, chest tightness) 2. Expiratory airflow limitation demonstrated on PFTs (FEV1/FVC less than LLN for age) 3. Expiratory airflow limitation has been shown to be variable 4. No alternative diagnosis is suspected

Question 19

By what age can young people be managed with asthma as per the adult algorithms?

Answer 19

Mid-adolescence 14-16 years

Question 20

True or false? Early puberty is an independent risk factor for persistence of asthma into adolescence and the severity of athsma in adulthood

Answer 20

True - but the mechanism is unclear (?effects of hormonal changes on reactivity of airways vs risk factors that are common to both asthma and early puberty)

Question 21

True or false? Increased BMI in girls has been associated with both early puberty and increased asthma risk

Answer 21

True.

Question 22

Is there a difference between asthma remission rates in adolescence between boys and girls?

Answer 22

Yes, boys have higher rates of remission after initially being the gender with higher prevalence in the 0-14 age group

Question 23

What is the recommendation for investigating asthma-like symptoms in adolescents and young adults?

Answer 23

Use spirometry to assess lung function objectively, even if the person had asthma during childhood

Question 24

What is the recommendation for investigating exercise-related asthma symptoms in adolescents?

Answer 24

Consider objective tests (exercise testing, bronchial provocation) or referral for investigation of possible non-asthma causes like poor CV fitness, hyperventilation or upper airways dysfunction

Question 25

In adults and adolescents, what symptoms constitute ‘good control’ of asthma?

Answer 25

All of: Daytime symptoms 2 or less times per week; need for reliever 2 or less times per week (not including if taken prophylactically before exercise); no limitation of activities, no night symptoms or on waking

Question 26

In adults and adolescents, what symptoms constitute ‘partial control’ of asthma?

Answer 26

1-2 of: daytime symptoms >2 days per week; need for reliever >2 days per week; any limitation in activities; any night symptoms or on waking

Question 27

In adults and adolescents, what symptoms constitute ‘poor control’ of asthma?

Answer 27

3 or more of: daytime symptoms > 2 days per week; Need for reliever >2 days per week; any limitation of activities, any symptoms during night or on waking

Question 28

When assessing asthma control, symptoms are based on those experienced in what recent time frame?

Answer 28

The past 4 weeks

Question 29

Low dose ICS treatment is indicated for adults and adolescents with asthma with what criteria? (Name 3)

Answer 29

Daytime symptoms 2 + times per month, any waking with asthma, any severe flare-up within the past year, or other risk factors for severe flare ups

Question 30

Name at least 4 risk factors for undiagnosed asthma among adolescents

Answer 30

Female, smoking (current and also exposure), low SES, family problems, low phyiscal activity and high body mass

Question 31

For adolescents with exercise-related wheeze and breathlessness, what common conditions should be considered in the diagnosis?

Answer 31

Poor CV fitness, exercise-induced upper airway dysfunction (spectrum of conditions characterised by inducible airway obstruction including vocal cord dysfunction) and exercise-induced hyperventilation

Question 32

What is the relationship between laughter-triggered wheeze in children and asthma?

Answer 32

Presence of resp symptoms that are triggered by laughing in children increases probability of symptoms being due to asthma (but laughter is a common cause of wheeze in infants)

Question 33

What is the relationship between the premenstrual/menstrual phase and asthma in women?

Answer 33

Asthma worsens in the premenstrual phase in up to 40% of women (?due to reduced response to corticosteroids and bronchodilators), perimenstrual worsening of asthma is relatively common among women with poorly controlled or severe asthma

Question 34

How is asthma defined clinically, as per the asthma handbook?

Answer 34

Asthma is defined clinically as the combination of variable respiratory symptoms (e.g. wheeze, SOB, cough and tightness) and excessive variation in lung function (variable airflow limitation)

Question 35

In regards to asthma, what is meant by ‘variable airflow limitation’?

Answer 35

Excessive variation in lung function - i.e., variation in expiration airflow that is greater than seen in healthy people

Question 36

What are ‘variable symptoms’ in asthma?

Answer 36

Respiratory symptoms (cough, tightness, wheeze, SOB) that vary over time and may be present or absent at any point in time

Question 37

Name some of the pathophysiological factors associated with untreated asthma

Answer 37

Chronic inflammation involving many cellular elements, airway hyperresponsiveness, intermittent airway narrowing (due to bronchoconstriction +/- congestion/oedema of bronchial mucosa +/- mucus

Question 38

What is the ‘gold standard’ test for diagnosing asthma?

Answer 38

This is a trick question - there is no single reliable test and no standard diagnostic criteria - the diagnosis is based on history, examination, consideration of other diagnoses and documentation of variable airflow limitation

Question 39

What spirometry findings are diagnostic for asthma?

Answer 39

1. Reversible airflow limitation (FEV1 increase 200mL or more and 12% or more from baseline). 2. Expiration airflow limitation (FEV1/FVC < LLN for age)

Question 40

Name at least 5 factors which make asthma more likely when investigating respiratory symptoms in a child

Answer 40

More than 1 of wheeze/cough/tightness/SOB; symptoms recurrent or seasonal, worse at night or early morning, hightory of allergies, symptoms clearly triggered by exercise/cold/irritants/allergens/viral infections/laughter; family history of atopy, widespread wheeze on auscultation, symptoms rapidly relieved by SABA, symptoms occurring when child doesn’t have a cold

Question 41

Name at least 5 factors which make asthma less likely when investigating respiratory symptoms

Answer 41

Dizziness, light headedness, peripheral tingling, isolated cough with no other respiratory symptoms, chronic sputum production, moist cough, normal exam when symptomatic, changes in voice, symptoms only present with URTI, normal PFTs when symptomatic

Question 42

Aside from asthma, list the other possible differential diagnoses for widespread wheeze on auscultation

Answer 42

COPD, viral/bacterial respiratory infection, tracheomalacia, inhaled foreign body, sometimes obesity alone

Question 43

Bronchodilator reversibility is performed on spirometry before and after administration of what dose of SABA?

Answer 43

4 puffs salbutamol 100mcg/actuation via pressurised MDI (then repeat testing 10-15 mins after)

Question 44

What is FEV1?

Answer 44

Forced expiratory volume over a specified time frame (1 = 1 second)

Question 45

What is the recommended management for an adult patient with suspected asthma, who shows some improvement in FEV1 after SABA but does not meet criteria for reversible airflow limitation?

Answer 45

Consider other investigations +/- trial of 4-6 weeks of regular low-dose ICS plus SABA PRN, with repeat spirometry following to see whether there is a significant improvement in symptoms and lung function

Question 46

Whilst peak expiratory flow meters/flow rate should not be used as a substitute for spirometry in asthma, it can support the diagnosis in some patients. What diagnostic parameters on peak flow are supportive of asthma?

Answer 46

Greater than 10% diurnal variation in peak expiratory flow rate with BD readings (averaged over 1 week) is suggestive

Question 47

What is peak flow measuring?

Answer 47

Gives an idea of how narrow or obstructed the airway is by measuring the maximum (peak) rate at which they can blow air into a peak flow meter after a deep breath.

Question 48

What is the definition of a ‘clinically important increase or decrease in lung function’ In the assessment of asthma?

Answer 48

Change in FEV1 of at least 200mL and 12% from baseline for adults (or at least 12% change from baseline for children) or a change in peak expiratory flow rate of at least 200% on the same meter

Question 49

Variable airflow limitation can be documented for patients if any of which criteria are met?

Answer 49

1. Clinically important increase in FEV1 after bronchodilator 2. Clinically important variation in lung function (20% change in FEV1) measured repeatedly over time 3. Clinically important reduction in lung function after exercise 4. Clinically important increase in lung function after a trial of 4 weeks with ICS 5. Clinically important variation in peak expiratory flow (diurnal variability greater than 10%) 6. Clinically important reduction in lung function during a test for airway hyper responsiveness (i.e., exercise challenge test or bronchial provocation)

Question 50

When investigating asthma in smokers and ex-smokers over 35 and in people over 65 years old, if expiratory airflow limitation is not completely reversible, what diagnoses should be considered?

Answer 50

COPD, or asthma-COPD overlap

Question 51

What is the definition of upper airway dysfunction, as per the Aus asthma handbook?

Answer 51

Intermittent, abnormal adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. It commonly mimicks and is misdiagnosed as asthma (can cause severe acute episodes of dyspnoea that occur unpredictably or due to exercise)

Question 52

What is the considered to be the best method to confirm the diagnosis of upper airway dysfunction?

Answer 52

Direct visualisation of the vocal cords

Question 53

Long acting B2 agonists (LABA) and long acting muscarinic antagonists (LAMA) should not be used by people with asthma-COPD overlap unless they are also taking which other medication?

Answer 53

ICS (either in combination or separately)

Question 54

In patients with asthma-COPD overlap, which medication forms an essential part of treatment and why?

Answer 54

Inhaled corticosteroid at low-moderate dose - to reduce the risk of potentially life-threatening flare ups, even if asthma symptoms appear mild or infrequent

Question 55

Most patients with asthma-COPD overlap will require treatment with an ICS plus which other medication?

Answer 55

A long acting bronchodilator (either a long acting B2 agonist or a long acting muscarinic antagonist)

Question 56

ICS treatment is associated with an increased risk of which other respiratory condition in people with COPD?

Answer 56

Non-fatal pneumonia

Question 57

Which patient groups are most likely to present with asthma-COPD overlap?

Answer 57

People with current asthma who have had significant exposure to smoking, people with long standing or late asthma who have become persistently SOB over time, people with significant smoking history and symptoms consistent with COPD who also have a history of childhood asthma, people who present in middle/late age with SOB who have a childhood asthma history but few symptoms in between and little smoking history

Question 58

Give 1 example of an ICS-LABA combination for treatment of asthma-COPD overlap that is taken once daily

Answer 58

Fluticasone furoate + vilanterol (Breo Ellipta 100/25)

Question 59

Give 1 example of an ICS-LABA combination for treatment of asthma-COPD overlap that is taken twice daily

Answer 59

Budesonide + formoterol (symbicort rapihaler or symbicort turbhaler)

Question 60

Give 1 example of a LABA for treatment of asthma-COPD overlap (ensure patient also using an ICS)

Answer 60

Salmeterol (BD dosing), aka Serevent accuhaler

Question 61

Give 1 example of a LAMA for treatment of asthma-COPD overlap (ensure patient also using an ICS)

Answer 61

Tiotropium (once daily), aka Spiriva or Spiriva Respimat. Another common example is Umeclidinium (Incruse Ellipta) which is also once daily, or Aclidinium (Genuair) which is twice daily

Question 62

Give 1 example of a LAMA/LABA for the treatment of asthma-COPD overlap that is taken once daily (ensure patient also taking an ICS)

Answer 62

Olodaterol + tiotropium (Spiolto Respimat)

Question 63

How can you confirm that airflow limitation is variable in an adult?

Answer 63

Based on showing variability in FEV1 on spirometry - Spirometry before and 10-15 minutes after a SABA, spirometry on separate visits, spirometry before and after exercise, spirometry before and after trial of ICS treatment, peak flow measured BD, in airway hyper responsiveness testing

Question 64

A clinical diagnosis of asthma is based on which factors?

Answer 64

Based on the probability that symptoms are due to asthma rather than another cause, and on the magnitude of deviation from the level of lung function and variation in lung function that is seen in a healthy population (i.e., demonstrating variable airflow limitation)

Question 65

After making a diagnosis of asthma in adults, what treatment should be commenced?

Answer 65

4-6 weeks of either a short acting beta 2 agonist PRN, or regular ICS (plus SABA PRN)

Question 66

List at least 5 conditions which can be confused with asthma in adults, and which are characterised by cough

Answer 66

Pertussis, GORD, rhinosinusitis, medications (ACE-1), bronchictasis, COPD, pulmonary fibrosis, large airway stenosis, habit-cough syndrome, inhaled foreign body

Question 67

List at least 2 conditions which can be confused with asthma in adults, and which are characterised by wheezing

Answer 67

Respiratory infections, COPD, upper airway dysfunction

Question 68

List at least 5 conditions which can be confused with asthma in adults, and which are characterised by difficulty breathing

Answer 68

Breathlessness due to poor CV fitness, hyperventilation, anxiety, chronic heart failure, pulmonary hypertension, lung cancer

Question 69

Assume a patient comes to see you with a history of asthma and already taking an ICS. On history, they report few respiratory symptoms, and spirometry does not demonstrate variable airflow limitation. What is the next recommended step in management?

Answer 69

If there is no clear history of prior variable airflow limitation, consider back titrating the preventer by 1 step. For ICS, reduce dose by 50%, and review spirometry 2-3 weeks later. If there is still no evidence of airflow limitation, consider stopping ICS and repeating spirometry again 2-3 weeks later.

Question 70

The possibility of work-related asthma should be considered if any of which 3 factors are present?

Answer 70

Timing of symptoms associated with work (especially if improve when away from work), exposure to substances known to cause occupational asthma, coworkers with respiratory symptoms

Question 71

List at least 3 occupations commonly associated with asthma triggers

Answer 71

Bakers, vehicle spray painters, healthcare workers, lab animal workers, agricultural workers

Question 72

Which special diagnostic tests can be used in adults to help identify emphysema or pulmonary fibrosis?

Answer 72

Lung volumes and diffusing capacity

Question 73

Which special diagnostic test can be used in adults presenting with asthma symptoms, where bronchiectasis is suspected?

Answer 73

High res CT

Question 74

In patients with asthma and chronic cough, name at least 7 findings which suggest a serious alternative or comorbid diagnoses that require further investigation?

Answer 74

Haemoptysis, smoker with > 20 pack year history, smoker aged 45+ years with new cough/voice change/changed cough, prominent dyspnoea esp at night, substantial sputum production, hoarseness, fever, weight loss, complicated reflux, swallowing disorders, recurrent pneumonia

Question 75

What are the main roles of bronchial provocation tests of airway hyperresponsiveness?

Answer 75

To exclude asthma as a cause of recurrent symptoms, and to confirm the presence of exercise-induced bronchoconstriction

Question 76

Name the types of bronchial provocation tests for airway hyperresponsiveness

Answer 76

Direct challenge tests (e.g., methacholine challenge test), indirect challenge tests (exercise challenge test, eucapnic volunatry hyperpnea, hypertonic saline, mannitol challenge test)

Question 77

What is the role of sputum eosinophillia testing in asthma diagnosis?

Answer 77

Patients with untreated asthma have airway inflammation (eosinophilic+/- neutrophilic) but testing is not essential for making the diagnosis if the patient shows clinical features of asthma and a low probability that it is due to another cause (and some asthma is not associated with eosinophilia)

Question 78

What is the role of peripheral blood eosinophil count in people with asthma?

Answer 78

In severe asthma, higher count is associated with greater risk of poor symptom control, and is important for predicting response to monoclonal antibody therapy (requirement for eligibility for some treatments)

Question 79

Presume you suspect allergic triggers in a patient with asthma. What is the next step in investigation?

Answer 79

Referral to a specialist allergist/appropriate provider for skin prick testing to common aeroallergens (need to minimise risk - this is the first line as per ASCIA)

Question 80

If skin prick testing is unavailable, and you wish to investigate suspected allergic triggers in a patient with asthma, what could be done?

Answer 80

Blood test (immunoassay for allergen specific IgE)

Question 81

List 3 medications which interfere with allergy skin prick testing

Answer 81

Antihistamines that cannot be withdrawn, TCAs or Pizotifen

Question 82

List at least 3 contraindications to allergy skin prick testing

Answer 82

Severe dermatographism, extensive skin rash, risk of anaphylaxis including occupational asthma due to latex sensitivity

Question 83

You have just made a diagnosis of asthma in an adult. They have symptoms less than twice per month, and never wake due to symptoms, and have no history of a flare up requiring steroids in the past 12 months. List an appropriate starting treatment regimen for this patient.

Answer 83

SABA as needed (Ventolin 100mcg, up to 12 puffs PRN with spacer)

Question 84

You have just made a diagnosis of asthma in an adult. They have symptoms 3 times per month and sometimes wake up due to symptoms. List an appropriate starting treatment regimen for this patient.

Answer 84

Regular low dose ICS + PRN SABA (or as needed low dose budesonide-formoterol, i.e., Symbicort)

Question 85

You have just made a diagnosis of asthma in an adult. They are having frequent daily symptoms on most days of the week. What is an appropriate starting treatment for this patient?

Answer 85

Medium to high dose ICS plus PRN SABA (with plan to down titrate ICS when symptoms improve). Or regular daily maintenance low dose ICS-LABA + PRN SABA (private script).

Question 86

You have just made a diagnosis of asthma in an adult. They are having severely uncontrolled symptoms, including waking every night. What is an appropriate starting treatment for this patient?

Answer 86

High dose ICS + PRN SABA OR daily ICS-LABA + PRN SABA. Could also consider short course of oral steroid in addition to an ICS based treatment

Question 87

Before spirometry, comment on the appropriate withholding times for SABA/SAMA, LABA, LAMAs

Answer 87

SABA/SAMA 4 hours. BD LABAs for 12 hours and once daily LABA for 2 hours. LAMA for 24 hours

Question 88

A diagnosis of asthma in children should not be made if cough is the only symptom and there are no signs of airflow limitation, such as _____ or ______

Answer 88

Wheeze, breathlessness

Question 89

List at least 4 physical examination signs of allergic rhinitis

Answer 89

Swollen turbinates, transverse nasal crease, mouth breathing, darkness and swelling under the eyes caused by sinus congestion, polyps

Question 90

It is a red flag for children aged 1-5 to present with signs/symptoms of asthma which had an onset very early in life, or from birth. What alternate diagnoses should be considered in these children?

Answer 90

CF, chronic lung disease of prematurity, primary ciliary dyskinesia, bronchopulmonary dysplasia, congenital abnormality

Question 91

In a child with crepitations on chest exam that do not clear with coughing, what serious illnesses need to be considered?

Answer 91

Lower respiratory tract conditions such as pneumonia, atelectasis and bronchiectasis

Question 92

What respiratory conditions in children can cause finger clubbing?

Answer 92

CF and bronchiectasis

Question 93

List 4 differentials for chronic wet cough lasting >4 weeks in a child aged 1-5

Answer 93

CF, bronchiectasis, chronic bronchitis, recurrent aspiration, immune abnormaltiy, ciliary dyskinesia

Question 94

What important serious condition should be considered in a child under 5 years old, presenting with asthma symptoms and nasal polyps?

Answer 94

CF

Question 95

What is the cause of wheeze and what does it’s presence suggest?

Answer 95

Turbulent airflow due to narrowing of intrathoracic airways, and indicates airflow limitation, irrespective of the underlying mechanism (i.e., bronchoconstriction or secretions)

Question 96

What is the most common symptom associated with asthma in children ages 5 and under?

Answer 96

Wheeze

Question 97

What is the most common cause of wheezing in an infant less than 12 months of age?

Answer 97

Acute viral bronchiolitis or small/floppy airways

Question 98

What is atopic asthma?

Answer 98

Asthma characterised by eosinophilic airway inflammation associated with sensitisation to aeroallergens (positive skin prick test or specific IgE on serology)

Question 99

What is the most common type of asthma in children?

Answer 99

Atopic asthma

Question 100

List at least 3 congenital conditions which are differentials for asthma in children aged 1-5

Answer 100

Structural airway problems (tracheomalacia, bronchopulmonary dysplasia, malformation causing narrowing of intra thoracic airways, vascular ring compressing bronchus, trachea-oesophageal fistula), CF, immune deficiency, primary ciliary dyskinesia, congenital heart disease

Question 101

List at least 3 infective conditions which are differentials for asthma in children aged 1-5

Answer 101

Bronchiolitis (ages <12 months), croup, chronic rhinosinusitis, recurrent resp tract infections, chronic suppurative lung disease

Question 102

List at least 3 acquired conditions which are differentials for asthma in children aged 1-5

Answer 102

Inhaled foreign body, GORD, recurrent aspiration, tumour or pulmonary oedema

Question 103

List at least 4 red flags for cough in children

Answer 103

Wet cough > 4 weeks, obvious difficulty breathing at rest or at night, systemic symptoms including failure to thrive, choking or vomiting, recurrent pneumonia, inspiratory stridor (other than in croup), abnormal resp exam, abnormal CXR findings, clubbing

Question 104

In children with no abnormalities detected on examination, CXR or spirometry, and no other asthma symptoms of airflow limitation, chronic cough is most likely to be due to which 3 causes?

Answer 104

Protracted bacterial bronchitis (resolves with 2-6 weeks antibiotics), post-viral (resolves with time), due to exposure to smoking or other pollutants

Question 105

True or false? Most cases of coughing in preschool children aged 1-5 are not due to asthma

Answer 105

True. Most likely due to recurrent viral bronchitis

Question 106

For what indications should a CXR be ordered for a child aged 1-5 presenting with wheeze and a differential diagnosis of asthma?

Answer 106

If unusual respiratory symptoms or if wheezing is localised

Question 107

Describe an appropriate treatment trial for preschool wheeze in a child older than 12 months

Answer 107

For episodes of wheeze associated with increased WOB, including if occurs in consult, given 2-4 puffs ventolin and observe response. If the increased WOB responds, consider whether a preventer is indicated (table in handbook with frequency of symptoms - i.e., always for kids who have had flares requiring ED/oral steroids etc, and consider in the community for symptoms every 4-6 weeks or less)

Question 108

In infants under 12 months old, what is the most likely cause of respiratory distress?

Answer 108

Bronchiolitis

Question 109

Bronchodilators are not recommended for children under what age?

Answer 109

12 months

Question 110

What care is recommended for a new plastic spacer prior to use?

Answer 110

Removal of electrostatic charge by washing in dishwashing liquid and allowing to air/drip dry without wiping or rinsing. Or, prime by actuating the device several times (though this wastes medicine)

Question 111

In spirometry, reduced _____ alone does not indicate that a child has asthma, becuase it may be seen with other lung diseases or be due to poor technique. However, reduced ____ for age indicates expiratory airflow limitation

Answer 111

FEV1; FEV1/FVC ratio

Question 112

A provisional diagnosis of asthma can be made in children 6 years and older if they have all of which 4 features?

Answer 112

1. Wheezing accompanied by breathing difficulty or cough 2. Other features that increase the probability of asthma such as history of allergic rhinitis, atopic dermatitis or a strong family history of asthma or allergies 3. no signs that suggest a serious alternative diagnosis 4. clinically important response to bronchodilator demonstrated on spirometry

Question 113

In the workup of asthma in a child older than 6, if asthma is suspected but spirometry does not demonstrate a clinically important response to bronchodilator, what can be done?

Answer 113

Repeat spirometry when the child has symptoms

Question 114

List and describe the 3 categories of frequency of asthma flareups in children

Answer 114

Infrequent intermittent (6 weekly symptoms and none in between); frequent intermittent (more than once every 6 weeks with no symptoms between); persistent (any of: daytime symptoms more than once/week, night symptoms more than twice/month or symptoms that restrict activity or sleep)

Question 115

List at least 2 examples of low dose ICS in children

Answer 115

Beclometasone diproprionate 100-200mcg (QVAR); budesonide 200-400mcg (Pulmicort); fluticasone proprionate 100-200mcg (Flixotide)

Question 116

List at least 3 examples of high dose ICS in children

Answer 116

Beclometasone diproprionate >200mcg (max 400); budesonide >400mcg (max 800); fluticasone proprionate >200mcg (max 500)

Question 117

What is the difference between indications for ICS in children 6 years and over with asthma vs children ages 1-5 with preschool wheeze?

Answer 117

In the 1-5 age group, depends on the frequency of symptoms/wheeze (once weekly up to 6 monthly or less) as well as severity. In the over 6’s it is based on frequency of flare ups and symptoms in between (i.e., infrequent intermittent, frequent intermittent, persistent) as well as the severity

Question 118

List the 5 asthma patterns in children 6 years and older who are not taking a regular preventer

Answer 118

Infrequent intermittent, frequent intermittent, persistent asthma (mild), persistent asthma (moderate), persistent asthma (severe)

Question 119

What is the definition of infrequent intermittent asthma in a child 6 years or older?

Answer 119

Symptom-free for at least 6 weeks at a time (flare ups up to once every 6 weeks but no symptoms in between)

Question 120

What is the definition of frequent intermittent asthma in a child 6 years or older?

Answer 120

Flare ups more than once every 6 weeks on average but no symptoms between flare ups

Question 121

What is the definition of mild persistent asthma in a child 6 years or older?

Answer 121

FEV1 greater than or equal to 80% predicted and at least 1 of: daytime symptoms more than once/week but not every day; night-time symptoms more than twice/month but not every week

Question 122

What is the definition of moderate persistent asthma in a child 6 years or older?

Answer 122

Any of: FEV1 <80% predicted, daytime symptoms daily, night time symptoms more than once/week, symptoms sometimes restricting activities/sleep

Question 123

What is the definition of severe persistent asthma in a child 6 years or older?

Answer 123

Any of: FEV1 less than or equal to 60% predicted, continual daytime symptoms, frequent night time symptoms, frequent flare ups, symptoms frequently restrict actitivy or sleep

Question 124

Children aged 6 or over who wheeze only during upper respiratory tract infections can be considered to have what diagnosis?

Answer 124

Episodic viral wheeze

Question 125

Dispensing _____ (number) ventolin canisters in a year is associated with an increased risk of asthma flareups in children, while ____(number) or more is associated with an increased risk of asthma death

Answer 125

3; 12

Question 126

What is the main reason why ICS have maximum dose cut offs in children?

Answer 126

Because above a certain threshold, the risk of adrenal suppression increases exponentially

Question 127

What sort of drug is montelukast?

Answer 127

Leukotrine receptor antagonist preventer

Question 128

What are the adverse effects of montelukast?

Answer 128

Behavioural and/or neuropsychiatric, including suicidality

Question 129

What advice should be given to patients with asthma in regards to ICS treatment during the covid pandemic?

Answer 129

Continue taking as prescribed, warn that stopping increases risk of severe asthma flare ups, including those triggered by viral infections, ensure asthma action plan up to date and they have access to all medications prescribed (avoid panic buying and hoarding), advise not to share puffers, encourage covid 19 vaccination

Question 130

True or false? ICS treatment is indicated for all adults, adolescents and children with asthma to reduce the risk of flares

Answer 130

False. ICS treatment is indicated in most adults and adolescents, whereas indications in chlidren depend on the age group and the pattern of symptoms and flare ups

Question 131

True or false? Monoclonal antibody (biologic) therapy for asthma (i.e., the ‘mabs’) are immunosuppresants

Answer 131

False.

Question 132

For patients with asthma taking biologic therapy, what is the advice regarding covid 19 vaccination?

Answer 132

Safe and should be immunised. If possible, the biologic shouldn’t be administered on the same day as the vaccine so that, should adverse effects occur, the cause will be easier to identify (ASCIA recommend not within 48 hours)

Question 133

COVID-19 is caused by a coronavirus from which family?

Answer 133

Betacoronavirus

Question 134

Describe the pathophysiology of covid 19 infection

Answer 134

Infection occurs when a spike glycoprotein on the virus surface attaches to the ACE-2 receptor on human epithelial cells in the mouth, nose and airways.

Question 135

What is the average incubation period of covid?

Answer 135

6 days

Question 136

At which days of covid 19 infection do symptoms typically worsen?

Answer 136

Days 4-9

Question 137

For how many days can covid aerosol particles survive on steel and plastic surfaces?

Answer 137

3 days

Question 138

What is the relationship between asthma and death from covid 19?

Answer 138

Overall, people with asthma are not an increased risk of infection or covid-related death, however use of oral corticosteroids used in the preceding year is associated with increased risk of death (presumably suggesting the severe or uncontrolled asthma is associated with higher risk)

Question 139

For adults and adolescents with asthma that has been well controlled for ___ months, consider stepping down therapy

Answer 139

2-3

Question 140

State 2 options that are considered to be suitable starting treatments for most new adult patients with asthma

Answer 140

Regular low dose ICS (e.g. Flixotide/fluticasone proprionate 100-200mcg/day) + PRN SABA (Salbutamol) or low dose budesonide-formoterol (Symbicort) PRN

Question 141

Which adult patients with new onset asthma as suitable to receive only PRN SABA as first line management?

Answer 141

Symptoms less than twice/month and no risk factors for flare ups (history of poor control, flare up in last 12 months, other lung disease, poor lung function, eosinophilic airway inflammation, exposure to cigarette smoke, low SES, mental illness)

Question 142

Give at least 3 example of low dose ICS in adults

Answer 142

Beclometasone diproprionate 100-200mcg (QVAR), budesonide 200-400mcg (Pulmicort), fluticasone proprionate 100-200mcg (Flixotide)

Question 143

List the 2 types of SABA available in Australia

Answer 143

Salbutamol (Ventolin/Asmol) and Tubutaline (Bricanyl). This category also includes low dose budesonide-formoterol (symbicort) PRN or as maintenance and reliever treatment)

Question 144

For an adult patient with new asthma with frequent or uncontrolled symptoms, name an appropriate initial treatment option (this is also the step up treatment option for adults with poorly controlled symptoms on basic initial treatment)

Answer 144

Regular daily low dose ICS-LABA (I.e., Seretide -Fluticasone Proprionate/salmeterol or Symbicort (budesonide/formoterol) which can be used as maintenance-and-reliever therapy with regular daily maintenance plus low dose as needed. OR Regular Daily Low dose mainenance ICS-LABA combination plus SABA as needed

Question 145

For patients with asthma not responding to regular daily low dose ICS-LABA, what is the step up treatment option?

Answer 145

Increase to medium-high dose of daily ICS-LABA (i.e., Symbicort as regular daily maintenance plus lose dose PRN). Or regular daily ICS-LABA at higher Doses + SABA as needed. Consider referral and add on treatments such as tiotropium

Question 146

When assessing asthma control in adults, what 4 criteria are indicative of good recent asthma symptom control?

Answer 146

Must have all 4 of: daytime symptoms 2 or less days/week, need for SABA 2 or less days/week, no limitation of activities and no symptoms at night or on waking

Question 147

When assessing asthma control in adults, which 4 criteria are considered to be indicative of partial or poor recent symptom control?

Answer 147

1 or 2 of the following is considered partial control, 3 or more considered poor control: daytime symptoms >2 days/week, needs for SABA >2 times/week, any limitation of activities, any symptoms at night or on waking

Question 148

For adult patients who are using SABA only for asthma symptoms, even if they meet the criteria for good control, in what situations would an ICS be indicated?

Answer 148

Daytime symptoms 2 or more times/month, any waking with asthma, any severe flare up within the past year, risk factors for severe flare ups

Question 149

What definition is used to identify asthma patients with high SABA use?

Answer 149

> 3 cannisters/year. These patients should have lung function checked

Question 150

List at least 5 risk factors associated with increased risk of life-threatening asthma

Answer 150

Intubation or admission to ICU ever, 2+ hospitalisations in past year; 3+ ED visits in the past year; hospitalisation/ED in past month, high SABA use, more then 3 cannisters/year, history of delayed presentation during flare ups, CVD, history of sudden onset acute asthma, sensitivity to unavoidable allergen, lack of action plan, SES disadvantage, living alone, mental illness, illicit substance use

Question 151

What are the 2 main factors associated with thunderstorm asthma?

Answer 151

Springtime allergic rhinitis, ryegrass pollen allergy

Question 152

Give at least 2 examples of questionnaire-based tools that can be used to standardise review of asthma symptoms in Australian patients

Answer 152

PACS - primary care asthma control screening tool. Asthma control questionnaire (ACQ)

Question 153

Give at least 3 examples of when spirometry can be helfpul in ongoing asthma management in adults

Answer 153

During a flare up to provide objective evidence of severity of bronchoconstriction, after a dose adjustment to measure response to treatment, to identify whether symptoms are due to non-asthma conditions (i.e., if FEV1 above 80-90% should prompt further Ix), identify patients who are poor perceivers of airflow limitation, rate of change of lung function decline

Question 154

List 3 pieces of advice that should be given to patients using PRN low dose budesonide-formoterol (Symbicort) as a reliever without a regular daily maintenance preventer

Answer 154

Use inhaler as needed for symptoms; take extra doses if symptoms increase; the Symbicort replaces any previous short acting reliever they had before; if they also get exercise-induced symptoms, consider using before exercise

Question 155

List the 3 uses of SABAs

Answer 155

Relieve asthma symptoms; prevent exercise-induced bronchoconstriction; relieve exercise-induced bronchoconstriction

Question 156

What is the duration of therapeutic effect of a SABA?

Answer 156

4 hours

Question 157

Explain why high use of SABAs may increase the risk of asthma flare ups

Answer 157

Regular use results in receptor tolerance (down regulation) to their bronchoprotective effects. This tolerance becomes more apparent with worsening bronchoconstriction which could lead to a poor response to emergency treatment

Question 158

What is the appropriate treatment setting for a patient with asthma who is requiring SABA at intervals less than 4 hours?

Answer 158

Needs medical supervision and ideally also receiving systemic corticosteroids

Question 159

In adults, how should use of an MDI inhaler + spacer be used?

Answer 159

In adults, shake the inhaler, breathe out all the way into the spacer, actuate a single puff into the spacer and then immediately take a slow deep breath from the spacer and then hold breath for 5 seconds. Tidal breathing through the spacer is used in acute asthma and for young children

Question 160

List the only 2 budesonide/formoterol inhalers that can be used as PRN regimens without concomittant maintenance treatment

Answer 160

Budesonide 200/formoterol 6mcg via dry powder inhaler (1 puff - Symbicort Turbihaler) and budesonide 100/formoterol 3mcg via MDI (2 puffs - Sympbicort rapihaler)

Question 161

LABAs for asthma should only be used when which other medicationis taken concurrently? (i.e., they are not appropriate for monotherapy alone)

Answer 161

Inhaled corticosteroids

Question 162

For adults with asthma who have very well controlled symptoms and who would prefer not to take a long term ICS, what is a suitable alternative?

Answer 162

PRN low dose budesonide-formoterol (Symbicort)

Question 163

List at least 4 known benefits of ICS in patients with asthma

Answer 163

Reduces symptoms, improves QOL, improves lung function, decreases airway hyperresponsiveness, controls airway inflammation, reduces frequency and severity of asthma flare ups, reduces risk of death due to asthma

Question 164

Most of the benefit of ICS is achieved with doses at the upper limit of the low dose range. State these dose ranges for 2 common ICS

Answer 164

Budesonide 400mcg (Pulmicort), fluticasone proprionate (Flixotide) 200mcg

Question 165

List at least 2 local and systemic adverse effects which can occur with higher doses of ICS

Answer 165

Local - hoarseness, candidiasis. Systemic - HPA axis changes, i.e., adrenal suppression

Question 166

The risk of adrenal suppression from high dose ICS is more common when patients are also taking which medications?

Answer 166

Those that inhibit cytochrome P450 (erythromycin, ketoconozole)

Question 167

Montelukast is less effective than ICS for controlling asthma symptoms in adults, but it may be considered as an alternative in which 2 main situations?

Answer 167

People who experience intolerable dysphonia with ICS despite correct technique, and people who refuse other preventer options (it can also have some favourable effects in patients with aspirin exacerbated respiratory disease)

Question 168

True or false? In adults with asthma that is not controlled by a low dose ICS, montelukast is the next most effective add on treatment

Answer 168

False. Montelukast is less effective than the addition of a LABA, and it is also associated with lesser improvement in lung function and QOL

Question 169

Give at least 2 appropriate standard initial maintenance doses of budesonide-formoterol (Symbicort) used in a maintenance-and-reliever regimen

Answer 169

Budesonide 200/formoterol 6mcg dry powder inhaler (1-2 inhalations BD, Symbicort Turbuhaler); budesonide 100/ formoterol 3mcg MDI (2-4 puffs BD - Symbicort Rapihaler)

Question 170

True or false? In adults whose asthma is not well controlled by taking low-dose ICS, switching to a combination ICS-LABA is more effective than increasing to a higher dose of ICS alone

Answer 170

True.

Question 171

What is the relationship to clinical outcome when starting preventer ICS-LABA in combination rather than with an ICS alone for patients with asthma?

Answer 171

The ICS-LABA is not more effective at reducing flare ups, but it does improve lung function, reduces symptoms and marginally reduces the requirement for SABA. It is not more effective in reducing the risk of flare ups that require treatment with an oral steroid compared with starting with a higher dose of ICS initially

Question 172

What dose adjustment should be expected when switching an asthma patient from an ICS to budesonide/formoterol combination as maintenance and reliever therapy?

Answer 172

It is expected that the maintenance dose of the ICS will be reduced

Question 173

What should be considered in step-down therapy of asthma management in pregnant women?

Answer 173

Only consider stepping down if the woman is taking an inappropriately high dose of a medicine - step down is not a priority in pregnancy due to the risk of flare up

Question 174

When stepping down adult asthma management, make small adjustments by reducing ICS dose by ____ at intervals of ____ by stepping down through the available doses

Answer 174

25-50% every 2-3 months

Question 175

For adolescents taking low dose ICS and symptoms have been well controlled for several months, consider switching to what therapy?

Answer 175

PRN low dose ICS-LABA or trial of cessation of ICS with planned follow up (do not offer cessation if there are any risk factors for severe flare ups)

Question 176

In regards to an asthma action plan for adults: for patients using a SABA only, what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 176

Start regular ICS preventer and continue for at least 2-4 weeks

Question 177

In regards to an asthma action plan for adults: for patients using PRN low dose budesonide-formoterol only, what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 177

Increase use as needed

Question 178

In regards to an asthma action plan for adults: for patients using an ICS preventer only, what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 178

Increase dose early (i.e., multiply dose by 4 for 7-14 days)

Question 179

In regards to an asthma action plan for adults: for patients using an ICS-LABA combination (budesonide-formoterol) on a maintenance-and-reliever regimen, what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 179

Take extra doses of Symbicort as needed to relieve symptoms (no more than 6 actuations at once and max 12 daily of dry powder, or 24 of the MDIs)

Question 180

In regards to an asthma action plan for adults: for patients using an ICS-LABA (budesonide-formoterol) on a maintenance only regimen + PRN SABA, what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 180

Increase dose of maintenance Symbicort for 7-14 days

Question 181

In regards to an asthma action plan for adults: for patients using an ICS-LABA combination with fluticasone proprionate-salmeterol (Seretide), what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 181

Increase ICS dose (multiply by 4) by adding a separate fluticasone proprionate inhaler for 7-14 days.

Question 182

List 5 pieces of advice that should be given to asthma patients who need long term high dose ICS to maintain good control

Answer 182

Check for oral thrush. Monitor BP and BGL. Should have BMD at baseline and repeated every 1-5 years. Have regular eye exams to check for cataracts and glaucoma, do regular weight bearing activity, have adequate dietary calcium intake and maintain adequate Vit D levels, consider screening for adrenal suppression

Question 183

In Australia, for which group of asthma patients may peak flow monitoring play a role in management?

Answer 183

Patients with severe asthma, history of frequent flare ups or poor perception of airflow limitation. Should be done BD and recorded.

Question 184

True or false? Patients with asthma should be advised not to take their preventer puffer before spirometry

Answer 184

False. But it should be documented whether they have taken a combination preventer that contains a LABA on the day. When spirometry is performed as a diagnostic test, inhaled bronchodilators should be withheld, but SABA should still be used for relief of symptoms. When spirometry is performed for monitoring, bronchodilators should not be witheld

Question 185

What does it mean to say that a patient with asthma as poor perception of airflow limitation?

Answer 185

Those who do not feel any different with a 15% increase or decrease in FEV1

Question 186

What is the clinical definition of a mild asthma flare up, and give an example of this?

Answer 186

Worsening of asthma control that is only just outside the normal range of variation for the individual. E.g., needing reliever more than usual, waking up with asthma, symptoms interfering with usual activities (a gradual reduction in PEF over several days)

Question 187

What is the clinical definition of a moderate asthma flare up, and give an example of this?

Answer 187

Events that are all of: troublesome/distressing, require a change in treatment, not life threatening and do not require hospitalisation. E.g., more symptoms than usual, increasing difficulty breathing, waking often at night with symptoms

Question 188

What is the clinical definition of a severe asthma flare up, and give an example of this?

Answer 188

Events that require urgent action by the patient or carers and health professionals to prevent a serious outcome such as hospitalisation or death. E.g., needing reliever again within 3 hours, difficulty with normal activity

Question 189

For adults with asthma, list the 4 situations where an increase in preventer and/or a course of oral steroids should be prescribed

Answer 189

For patients with any of: acute asthma symptoms that recur within 3 hours of taking SABA; increasing difficulty breathing over one or more days; night time asthma symptoms that interfere with sleep over more than 1 night in a row; peak flow below what is normal for the patient (pre agreed based on clinical history)

Question 190

List an appropriate treatment regime of oral corticosteroids for adults who require additional treatment for asthma

Answer 190

Oral prednisolone 37.5mg - 50mg for 5-10 days (not necessary to taper if course is less than 14 days)

Question 191

True or false? Pregnancy is a contraindication for oral steroids in asthma exacerbations

Answer 191

False. Oral prednisolone is rated category A for pregnancy

Question 192

In patients taking maintenance combination fluticasone proprionate/salmeterol (Seretide), ensure that the total daily dose is ______ during a flare up

Answer 192

Total daily dose of salmeterol 100mcg/day (e.g., if patient taking Seretide 250/25 1 puff BD, increase this to 2 puffs BD, or prescribe an additional fluticasone proprionate inhaler for 1-2 weeks to keep the salmeterol dose the same)

Question 193

What should be documented in the asthma action plan for an adult patient who is taking budesonide-formoterol as maintenance-and-reliever treatment with a dry powder inhaler, and suffers from a flare up of symptoms?

Answer 193

Take 1 extra puff when needing relief from symptoms. If needing more than 6 reliever inhalations per day for more than 2-3 days, take action by seeing GP or starting oral steroid course. Present to ED/GP if needing more than 12 puffs in 1 day (but keep taking whilst waiting)

Question 194

What should be documented in the asthma action plan for an adult patient who is taking budesonide-formoterol as maintenance-and-reliever treatment with an MDI, and suffers from a flare up of symptoms?

Answer 194

Take 2 extra puffs when needing relief from symptoms. If needing more than 12 puffs/day for 2-3 days, take action by contacting GP or starting course of oral steroids. Present to ED/GP if needing more than 24 puffs in 24 hours (keep taking whilst waiting)

Question 195

What should be documented in the asthma action plan for an adult patient who is taking PRN low dose budesonide-formoterol only with a dry powder inhaler, and suffers from a flare up of symptoms?

Answer 195

Take more doses if symptoms worsen or do not improve, contact GP/start oral steroids if needing more than 6 puffs per day for 2-3 days, and present to ED/GP if needing more than 12 puffs/day

Question 196

What should be documented in the asthma action plan for an adult patient who is taking PRN low dose budesonide-formoterol only with an MDI, and suffers from a flare up of symptoms?

Answer 196

Take more doses if symptoms worsen or do not improve, contact GP/start oral steroids if needing more than 12 puffs/day for 2-3 days. Go to ED/GP if needing more than 24 inhalations/day

Question 197

When should patients reduce their preventer dose back to normal after an exacerbation?

Answer 197

After 2 weeks

Question 198

What is the definition of severe asthma in adults?

Answer 198

Asthma that remains uncontrolled despite regular treatment with high dose ICS + LABA or with maintenance oral steroids, or asthma that requires this level of treatment (Step 4) to prevent it becoming uncontrolled

Question 199

For adults with severe asthma, give at least 3 examples of ways to optimise their treatment regimen

Answer 199

Consider trial of add on tiotropium (LAMA), consider trial of high dose ICS for 3-6 months, consider trial of add-on montelukast (though evidence is poor). For patients on ICS-LABA and using PRN SABA as a reliever, consider changing to a low dose ICS-LABA for single maintence and reliever therapy to reduce the risk of flare ups

Question 200

Give at least 4 indications to refer a patient with severe asthma to a Specialist

Answer 200

Prolonged high dose ICS required for control, needing maintenance with oral steroid or frequent courses, use of SABA 6-8 puffs/day for several weeks despite appropriate maintenance treatment, frequent or sudden flare ups, if food allergy is suspected

Question 201

Asthma in adults is considered to be uncontrolled if any of which symptoms are present?

Answer 201

Poor symptom control (during night/waking, limitation of activities, daytime symptoms 2+ days/week, need for SABA 2+ days/week), frequent severe flare ups (more than 1 flare requiring oral steroid in the past year), serious flare up (hospital admission in the past year), persistent airflow limitation detected on spirometry

Question 202

True or false? Severe asthma most commonly first presents as milder asthma which eventually progresses

Answer 202

False. Severe asthma seems to be a distinct disease with different pathology, and it is rare for mild asthma to progress to severe asthma

Question 203

People with asthma tend to have more symptoms of reflux. Give one postulated explanation for this.

Answer 203

Via changes in intrathoracic pressure, or from the effects of asthma medications on the gastrooesophageal sphincter. GORD may contribute to bronchoconstriction through vagally mediated reflexes, airwy hyperresponsiveness, chornic microaspiration of gastric fluid etc.

Question 204

List at least 5 common agents associated with irritant-induced occupational asthma

Answer 204

Bleaches, cleaning agents, sealants, diesel exhaust, sulphur dioxide, ammonia, chlorine, chlorofluorocarbons

Question 205

List at least 5 disorders which are independent risk factors for worse asthma control/increased flare ups

Answer 205

Obesity, allergic rhinitis, OSA, reflux, anxiety disorder

Question 206

Foods are rarely a trigger for asthma. Name 3 foods which have been shown to be associated in some cases

Answer 206

Sulphite additives (processed foods, dried fruit, medicines, beer and wine), wine, thermal effects (cold drinks etc)

Question 207

List at least 3 medicines which can worsen asthma

Answer 207

Beta blockers, anticholinesterases and cholinergics, complementary medicines such as echinacea, bee products, those containing salicylates such as willowbark

Question 208

List 1-2 cardio selective beta blockers that may be used with extreme caution in asthma, and 1-2 which are non selective and must not be used

Answer 208

Cardioselective beta blockers target receptors in the heart, these include atenolol, bisoprolol, metoprolol and nebivolol. Nonselective beta blockers target both alpha-1 and beta-2 receptors, thereby having the potential to cause bronchoconstriction in the lungs. Examples include cervedilol, labetolol and propanolol

Question 209

Give some examples of cholinesterase inhibitors that should be used with caution in people with asthma

Answer 209

Neostigmine, donepazil, rivastigmine, galantamine

Question 210

List at least 1 of the 4 monoclonal antibody therapies that are available in Australia for the treatment of patients with severe eosinophilic or allergic asthma which is uncontrolled despite optimised standard treatment

Answer 210

Omalizumab, mepolizumab, benralizumab, dupilumab

Question 211

Which non-pharmacological treatment is recommended for adults with asthma and mucus production?

Answer 211

Referral to a physio or online video to learn Active Cycle of Breathing technique

Question 212

Bisphosphonates are recommended for primary fracture prevention in which circumstances?

Answer 212

Glucocorticoid-induced OP T score less than or equal to -1.5, patients with osteopenia (T score less than or equal to 1) treated with 7.5mg or more of pred/day for 3 months or more

Question 213

Patients with severe asthma should be given what advice regarding immunisation?

Answer 213

Recommend annual fluvax and pneumococcal

Question 214

Azithromycin and clarithromycin are sometimes used in the management of which chronic respiratory conditions to reduce exacerbation rates?

Answer 214

CF, bronchiectasis, COPD

Question 215

Oral corticosteroid use in adults with asthma is associated with which serious adverse events? (Name at least 4)

Answer 215

Severe infections, peptic ulcers, affective disorders, cataracts, CV events including MI and HTN, diabetes, fractures and OP

Question 216

For children aged 1-5 with preschool wheeze where a reliever is prescribed, when should parents be educated to give (and not give)?

Answer 216

Reliever should be used when wheezing episodes are associated with increased WOB. Not for cough in the absence of other symptoms, and not for noisy breathing in infants with no increased WOB

Question 217

In children aged 1-5, quote the stepped ladder for treatment for asthma

Answer 217

1. SABA only, 2. Add preventer with either low dose ICS or montelukast, 3. step up to low dose ICS AND montelukast, OR high paediatric dose ICS

Question 218

Which children aged 1-5 with preschool wheeze should be considered for preventative treatment

Answer 218

Those with symptoms every 4-6 months. Any child with symptoms at least once/week, or who have moderate flare ups or worse (requiring ED/oral steroids etc.) should get a preventer.

Question 219

Quote the appropriate treatment of a reliever to prescribe to a child aged 1-5 with salbutamol responsive preschool wheeze

Answer 219

Salbutamol 2-4 puffs (100mcg per puff) as needed

Question 220

For children aged 12 months to less than 2 years, consider a treatment trial with low dose ICS only if any of which 3 factors apply?

Answer 220

Symptoms (wheezing, cough, breathlessness) occur at least once/week and frequently disrupt sleep or play, flare ups severe enough to require ED or oral steroid, flare up that requires hospitalisation

Question 221

List the conditions whereby montelukast may be chosen as the preventer of choice in children aged 1-5 with preschool wheeze

Answer 221

Unable to use or refuses MDI + spacer/mask, if significant allergic rhinitis that requires threatment, if parents decline steroid treatment

Question 222

List at least 3 adverse effects of SABAs in children aged 1-5

Answer 222

Muscle tremor, palpitations, agitation (hypokalaemia at very high doses)

Question 223

What is the step-down advice for children aged 1-5 who have had good symptom control for at least 6 months whilst on an ICS?

Answer 223

Reduce dose and monitor sontrol within 4-6 weeks, and do not attempt to step down treatment at the start of the preschool year or during the child’s peak asthma season if this is predictable.

Question 224

When should a 1-5 year old child with wheeze be considered for oral steroids, and what dose is appropriate?

Answer 224

For those with acute asthma/wheeze with increased WOB severe enough to require hospital admission. The dose is 1mg/kg prednisolone (max 50mg) each morning for 3 days

Question 225

When should a 1-5 year old child be prescribed an oral steroid for use as part of an asthma action plan?

Answer 225

Never, the child always needs to be reviewed

Question 226

In regards to management of acute flare ups in children (up to 12), what is different in the advice regarding ICS treatment when compared to adults with exacerbations?

Answer 226

In kids, there is no evidence to support increasing the dose or adding an ICS during exacerbations

Question 227

When is regular preventer treatment indicated in children over 6 with asthma?

Answer 227

Frequent intermittent asthma (flare ups every 6 weeks or more often) or persistent symptoms (daytime asthma symptoms more than once/week or night symptoms more than twice/month) and those with severe flare ups irrespective of the frequency or symptoms between

Question 228

Which children aged 6+ should be considered for preventative treatment?

Answer 228

Any child with frequent intermittent flare ups (more than once every 6 weeks without symptoms between), persistent flare ups (any of day symptoms > 1/week, night symptoms >2/month or restricting activity or sleep), and any child with at least moderate severity flare ups requiring ED/oral steroids)

Question 229

In children aged 6+, quote the stepped ladder for treatment for asthma

Answer 229

1. SABA as needed, 2. Add low dose ICS OR montelukast, 3. Change to high dose ICS OR low dose ICS/LABA OR low dose ICS + montelukast

Question 230

List and define the 3 levels of recent asthma symptom control in children

Answer 230

Good control (all of: daytime symptoms 2 or less times/week, rapidly relieved by SABA, no limitation of activities, no symptoms at night or on waking, SABA 2 or less days/week). Partial control (any of: day symptoms > 2 days/week, any limitation of activities, any symptoms at night or on waking, need for SABA > 2 days/week). Poor control (Either of: daytime symptoms >2 days/week lasting minutes/hours or recurring OR 3 or more features of partial control within the same week)

Question 231

What is the step-down advice for children aged 6+ who have had good symptom control for at least 6 months whilst on a combined ICS-LABA?

Answer 231

Consider switching to a low dose ICS only, monitor symptom control 4-6 weeks after and do not attemp to step down at the start of the preschool year or during peak asthma season if predictable.

Question 232

Which combination inhaler is approved by the TGA for use in children 4 years and older?

Answer 232

Fluticasone proprionate + salmeterol (Seretide) - though unlike in adults not shown to be associated with significant reduction in flare ups compared to ICS alone

Question 233

For children 6+ who are suspected to have asthma, how often should spirometry be performed?

Answer 233

If normal, repeat annually at asthma reviews. If abnormal, check again 4-6 weeks after starting or changing treatment

Question 234

What is the role of Tiotropium in the treatment of asthma in children?

Answer 234

Approved for children over the age of 6 with moderate to severe asthma, and prescribed by a specialist

Question 235

In children over 6 who have persistent exercise induced respiratory symptoms despite regular treatment with inhaled corticosteroids, consider adding which other medication?

Answer 235

Montelukast (though not all children will get a response)

Question 236

List the most common bahavioural and/or neuropsychiatric adverse effects of montelukast

Answer 236

Nightmares, sleep disturbance, anxiety, irritability, agrression and depression

Question 237

What treatment is recommended for a child 6+ years who has asthma and symptoms have been well controlled for at least 6 months whilst taking a regular ICS?

Answer 237

Consider reducing the dose (or ceasing if already on lowest dose), and monitor symptom control with repeat spirometry in 4-6 weeks (and don’t step down at start of school year or during child’s peak asthma season if predictable)

Question 238

What treatment is recommended for a child 6+ years who has asthma and symptoms have been well controlled for at least 6 months whilst taking a regular combination ICS + LABA?

Answer 238

Consider halving the dose. If the ICS dose is already low, replace the combination inhaler with ICS alone. Monitor symptom control in 4-6 weeks (and don’t step down at start of school year or during child’s peak asthma season if predictable)

Question 239

What treatment is recommended for a chlild 6+ years who has acute asthma and is needing SABA approximately every 4 hours over a 24 hour period?

Answer 239

Short course of prednisolone (1mg/kg (max 50mg) each morning for 3 days

Question 240

For children 6+ who have uncontrolled asthma, what other add-on treatment is approved for use providing that the child has been seen for at least 6 months by a specialist?

Answer 240

Monoclonal antibody Omalizumab

Question 241

What advice should be given to parents for washing spacers?

Answer 241

Clean no more often than monthly, and after infection. Always air dry without rinsing or wiping.

Question 242

List at least 7 risk factors for life-threatening asthma flare ups in children

Answer 242

Poor control, admission to hospital in past 12 months, history of intubation for acute asthma, overuse of SABA, abnormal spirometry, poor adherence to preventer or action plan, exposure to allergens or smoke, obesity, other allergies, family factors

Question 243

Sensitisation to which allergen is almost universal in patients who have reported flare ups of asthma consistent with thunderstorm asthma in Australia?

Answer 243

Rye grass allergen

Question 244

List the 2 forms of specific allergen immunotherapy available in Australia

Answer 244

Sublingual immunotherapy, subcutaneous immunotherapy

Question 245

Both forms of allergen immunotherapy for asthma in Australia require what treatment duration?

Answer 245

3-5 years (and can be repeated)

Question 246

True or false? Food allergy is a risk factor for life-threatening asthma flare ups

Answer 246

True.

Question 247

Give one example of a validated checklist for assessing recent asthma control in children

Answer 247

Test for Respiratory and Asthma Control in Kids (TRACK)

Question 248

What red flags should parents be educated to watch for in rgeards to adrenal insufficiency in a child who has required high dose ICS for 6 months or longer

Answer 248

Lethargy, vomiting, abdominal pain, seziures

Question 249

What is the standard screening test for adrenal suppression in children? What is the next investigation if this is abnormal?

Answer 249

Morning cortisol lecel. If abormal, followed up with a low-dose adrenocorticotropic hormone stimulation test.

Question 250

Briefly describe the recommended steps for asthma first aid for community members

Answer 250

Rule of 4’s - Sit person upright and give 4 puffs of a reliever (4 breaths to 1 puff), wait 4 minutes and give 4 more breaths if needed

Question 251

If a person is having an asthma attack in the community and ventolin is not available, what other puffers could be used if they were available?

Answer 251

Symbicort (budesonide/formoterol - ICS/LABA) or Bricanyl (terbutaline - SABA)

Question 252

Consider an asthma action plan for adults. If the usual treatment includes a SABA only (only appropriate for symptoms < twice/month, no waking, no severe flare up within the past year, no other risk factors for severe flares), what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 252

Start regular ICS preventer and continue for at least 2-4 weeks

Question 253

Consider an asthma action plan for adults. If the usual treatment includes PRN budesonide-formoterol only (i.e., Symbicort - no maintenance treatment) what is the suggested first line strategy for adjusting treatment when symptoms worsen?

Answer 253

Increase use as needed

Question 254

Which patients with asthma are particularly at risk of thunderstorm asthma?

Answer 254

Those with seasonal (springtime) allergic rhinitis (i.e., probably allergic to ryegrass pollen) and live in or are travelling to an area with high grass pollen levels.

Question 255

List at least 3 strategies that may be helpful in avoiding pollen in patients who are sensitised to pollens

Answer 255

Stay indoor during and after thumderstorms, stay indoors on high pollen and windy days, wear sunglasses to prevent allergens from depositing onto the conjunctiva, wash and dry clothes inside to prevent deposition of pollen onto clean clothes, keep windows closed where possible

Question 256

When should oxygen therapy be administered to adult vs children in acute asthma?

Answer 256

If <92% in adults, or <95% in children

Question 257

Within what timeframe shouls systemic corticosteroids be given in acute asthma? What is the dose?

Answer 257

Within the first hour. In kids, give 1mg/kg prednisolone (assuming patient can take oral medication), in adults, give 50mg. Continue for 5-10 days.

Question 258

Patients who present with an asthma attack should be observed for __ hours after respiratory distress/WOB has resolved

Answer 258

3

Question 259

Nebulisers can generate aerosol droplets that can spread for several metres and remain airborne for more than ___ minutes

Answer 259

30

Question 260

True or false? Wheezing infants younger than 12 months old should not be treated for acute asthma

Answer 260

True - acute wheeze in this age group is most commonly due to acute viral bronchitis

Question 261

What is the definition of a mild flare-up/exacerbation of asthma? Provide 1 example

Answer 261

Worsening of asthma control that is only just outside the normal range of variation for the patient (i.e., more symptoms thatn usual, needing reliever more than usual, waking up with asthma)

Question 262

What is the definition of a moderate flare-up/exacerbation of asthma? Provide 1 example

Answer 262

Events that are all of: troublesome or distressing, require a change in treatment, not life threatening, do not require hospitalisation. E.g., more symptoms than usual, difficulty breathing, waking often at night

Question 263

What is the definition of a severe flare-up/exacerbation of asthma? Provide 1 example

Answer 263

Events that require urgent action by the patient (or carers) and health professionals to prevent a serious outcome such as hospitalisation or death from asthma (i.e., needing reliever again within 3 hours, difficulty with normal daily activities)

Question 264

What is the definition of “severe asthma”?

Answer 264

Asthma that is uncontrolled despite treatment with a high dose of ICS in combination with a LABA (with correct inhaler technique and adherence) or maintenance oral corticosteroids, or that requires such treamtment to prevent it from becoming uncontrolled

Question 265

If an adult patient with acute asthma has poor response to initial management with SABA +/- ipratropium, what is the next line of therapy and the dose?

Answer 265

Add IV Magnesium sulfate - 10mmol as a single IV solution over 20 minutes (for a child, the dose is 0.1-0.2 mmol/kg to a max of 10mmol)

Question 266

In both adults and children presenting with acute asthma, what are the signs of mild/moderate severity on rapid primary assessment?

Answer 266

Can walk, speak whole sentenses in one breath, sats >94%

Question 267

In both adults and children presenting with acute asthma, what are the signs of severe severity on rapid primary assessment?

Answer 267

Any of: increased work of breathing, unable to complete sentences in one breath due to dyspnoea, obvious respiratory distress, oxygen saturation 90-94%

Question 268

In both adults and children presenting with acute asthma, what are the signs of life threatening severity on rapid primary assessment?

Answer 268

Any of: reduced consciousness or collapse, exhaustion, cyanosis, sats <90%, poor respiratory effort, soft/absent breath sounds

Question 269

List at least 3 featres of salbutamol toxicity

Answer 269

Tachycardia, tachypnoea, metabolic acidosis, hypokalaemia

Question 270

Explain why oxygen should not routinely be given to adults with acute asthma, when sats 95% or higher

Answer 270

Because over-oxygenation increases the risk of hypercapnoea

Question 271

Give at least 3 examples of when a patient with acute asthma should be considered for adrenaline therapy

Answer 271

If the patient is unresponsive, cannot inhale bronchodilators or is considered to be periarrest, when anaphylaxis is suspected. Can be used in life-threatening asthma if there is no response to other bronchodilators and condition is rapidly deteriorating

Question 272

True or false? Pregnant women presenting with acute asthma should be given salbutamol and oral steroids as indicated, just as for non-pregnant patients

Answer 272

True - pregnant women who present with acute asthma should receieve treatment immediatley to minimise the risk to both the foetus and woman

Question 273

What is the main cause of death due to asthma?

Answer 273

Hypoxia

Question 274

In which situations should non invasive ventilation be considered in acute asthma?

Answer 274

If the patient is starting to tire or develops type 2 respiratory failure

Question 275

For a patient presenting with acute asthma, when should mechanical ventilation be used?

Answer 275

Respiratory arrest, acute respiratory failure that does not respons to treatment or failure to respond to NIV

Question 276

Quote the normal HR and RR for children 5-12 years

Answer 276

HR 80-120, RR 20-25

Question 277

Quote the normal HR and RR for children 12-18 years

Answer 277

HR 60-100, RR 15-20

Question 278

Name 4 situations where a CXR may be considered in a patient presenting with acute asthma

Answer 278

If pneumonia, atelectasis, pneumothorax or pneumomediastinum is suspected

Question 279

When should an ABG be considered for adult patients presenting with acute asthma?

Answer 279

If Sp02 < 92%, or if, after treatment has been initiated, any of the following are present: inability to speak due to dyspnoea, reduced consciousness or collapse, exhaustian, cyanosis, poor respiratory effort, cardiac arrythmia

Question 280

List at least 5 reasons to consider hospital admission for both adults and children presenting with acute asthma

Answer 280

Similar features: hypoxia on presentation, ongoing resp distress/WOB 1-2 hours after presentation, history of ICU admission for asthma, presentation within the past 4 weeks, high use of SABA, if unable to be appropriately monitored at home. For adults, consider spirometry at 1 hour check and admit if FEV1 <60% predicted. For kids, admit if there is a concurrent confirmed food allergy (risk of death is higher)

Question 281

What is the dose of IM adrenaline which may be given in asthma emergencies where the patient is not responding to standard treatment and whois continuing to deteriorate?

Answer 281

1:1000, 0.01mg/kg up to 0.5mg (0.5mL), repeat every 3-5 mins if needed

Question 282

What examination test/manouvre may be used in adults 1 hour after presentation with acute asthma, which may be a useful indicator of adequate recovery/response to treatment?

Answer 282

The lie down test - ability to lie flat without dyspnoea 1 hour after prestnation may be indicative of adequate recovery and appropriate discharge from the ED

Question 283

What dose of ICS is indicated for all adults and adolescents who have had an asthma flare up within the past 12 months?

Answer 283

Low dose

Question 284

What follow up is recommended for all patients who have been discharged from hospital/ED after an acute asthma episode?

Answer 284

GP check up in 3 days, and comprehensive assessment in 2-4 weeks

Question 285

List at least 4 comorbid medical conditions that may affect asthma control

Answer 285

Uncontrolled allergic rhinitis/thinosinusitis, GORD, obesity, nasal polyps, upper aiways dysfunction, CVD

Question 286

Most people with asthma have what other disease process?

Answer 286

Allergies

Question 287

What are the examination findings in a patient with allergic rhinitis?

Answer 287

Swollen turbinates, transverse nasal crease, reduced nasal airflow, mouth breathing, darkness and swelling under the eyes caused by sinus congestion

Question 288

Describe the pattern of symptoms seen in intermittent allergic rhinitis in adults and adolescents

Answer 288

Either of: symptoms <4 days/week; symptoms present < 4 consecutive weeks

Question 289

Describe the pattern of symptoms seen in persistent allergic rhinitis in adults and adolescents

Answer 289

Both of: symptoms present >4 days/week and present >4 consecutive weeks

Question 290

Describe the pattern of symptoms in mild vs moderate-to-severe allergic rhinitis in adults and adolescents

Answer 290

Moderate-to-severe include any of: sleep disturbance, impairment of ADLs or leisure; impairment of school/work; troublesome symptoms. Mild severity is defined by the absence of all of these features

Question 291

For adults and adolescents with mild intermittent allergic rhinitis, consider starting treatment with which medications? What if symptoms do not improve significantly within 2 weeks?

Answer 291

Intranasal H1 antihistamine or second generation less sedating oral antihistamine. If no improvement, switch to an intranasal corticosteroid.

Question 292

For adults and adolescents with seasonal allergic rhinitis, what medication can be considered as an alternative to antihistamines?

Answer 292

Montelukast

Question 293

What is the next line in management for adults and adolescents with allergic rhinitis who have had incomplete response to a trial of intranasal corticosteroid?

Answer 293

Add antranasal anithistamine and continue both

Question 294

Which pathology should be suspected in children with allergic rhinitis which does not respond to regular intranasal corticosteroids within 4 weeks?

Answer 294

Adenoid hypertrophy - refer these patients

Question 295

For children who are taking an ICS for asthma and who have persistent allergic rhinitis symptoms despite treatment with an intranasal corticosteroid, consider adding _____

Answer 295

Montelukast

Question 296

Name at least 4 of the most common comorbid conditions in people with asthma

Answer 296

Allergic rhinitis, rhinosinusitis, GORD, mental illness, chronic infections and OSA

Question 297

Some complementary medicines have caused serious allergic reactions in some patients with asthma. Name 3 examples.

Answer 297

Echinacea, bee products, garlic supplements

Question 298

Cold air can trigger asthma symptoms due to which 2 mechanisms?

Answer 298

1. Response to sudden cooling of the airways 2. Reflex-mediated lower airway response to cooling of the skin or upper airways

Question 299

What is the definition of occupational asthma?

Answer 299

New-onset asthma caused by an exposure to an airborne substance in the workplace (sensitiser or irritant)

Question 300

In which situations should the possibility of COPD or asthma-COPD overlap be considered as an alternative diagnosis in patients presenting with respiratory symptoms?

Answer 300

Current smoker or history of smoking and age > 25, exposure to environmental tobacco or other smoke, age 55 and over, longstanding asthma

Question 301

What is the pathogenesis of exercise-induced bronchoconstriction in non-athletes?

Answer 301

Occurs when ventilatory rate is high and the airways must heat and humidify a large volume of air in a short time. Dehydration of the airway leads to release of inflammatory mediators within the airway and contraction of airway smooth muscle

Question 302

What is the pathogenesis of exercise-induced bronchoconstriction in athletes?

Answer 302

Probably due to chronic injury to the airway epithelium assocaited with long-term frequent prolonged high ventilation rates in the presence of environmental exposure to cold/dry air and airborne pollutants

Question 303

What is the usual timing of symptoms in exercise-induced bronchoconstriction in patients with asthma?

Answer 303

Symptoms usually worst 5-10 minutes after stopping exercise, rather than during

Question 304

What are the symptoms of exercise-induced bronchoconstriction?

Answer 304

Cough, wheeze, feeling tight in the chest, breathlessness, excessive mucus production

Question 305

Name 2 appropriate treatment options for adults/adolescents with asthma who have symptoms less than twice/month and no risk factors for flare ups, who do not use an ICS but who give symptoms consisted with exercise-induced bronchoconstriction

Answer 305

1. Salbutamol 1-4 puffs 15 minutes before exercise, 2. Switch to PRN low dose budesomide-formoterol (symbicort) instead of as needed salbutamol

Question 306

Name the 2 forms of occupational asthma

Answer 306

1. Sensitiser-induced occupational asthma (allergic mechanism) 2. Irritant-induced occupational asthma (non-alergic mechanism)

Question 307

What is the clinical definition of COPD?

Answer 307

Persistent airflow limitation resulting from a combination between small airways disease and elvolar destruction

Question 308

Not all patients with COPD have a history of smoking. Name 5 other risk factors for development of COPD

Answer 308

Exposure to tobacco smoke, prenatal smoking, preterm birth, respiratory illneses in childhood, asthma, occupational exposure to dust and fumes, genetic susceptibility

Question 309

Name the 5 main symptoms that are suggestive of COPD

Answer 309

Breathlessness, cough, sputum production, wheeze, recurrent respiratory tract infection

Question 310

What spirometry finding is diagnostic of COPD?

Answer 310

Post bronchodilator FEV1/FVC ratio less than 0.7

Question 311

All patients with COPD can benefit from which 5 general management measures?

Answer 311

Stopping smoking, physical activity, immunisation, pulmonary rehabilitation and good nutrition

Question 312

True or false? Pharmacological treatment of COPD improves mortality

Answer 312

False. Drug treatment improves symptoms and QOL, and reduces frequency of exacerbations, but the affect on mortality remains unclear

Question 313

Describe the step up therapy in COPD

Answer 313

SABA, then LABA or LAMA monotherapy, then LAMA plus LABA dual therapy, then triple therapy with LAMA.LAMA/ICS

Question 314

ICS therapy can be added to LAMA+LABA therapy in COPD, only when which 2 criteria are met?

Answer 314

1. Severe exacerbation requiring hospital admission or at least 2 moderate exacerbations in the past 12 months 2. significant symptoms despite dual therapy with LAMA + LABA

Question 315

What is the only intervention shown to improve the natural history/slow the progression of COPD?

Answer 315

Smoking cessation

Question 316

Which is currently the only LABA available on the PBS for monotherapy step 2 of COPD treatment?

Answer 316

Indaceterol 150mcg (Onbrez Breezhaler)

Question 317

In COPD, triple therapy with LAMA/LABA/ICS is only required in which group of patients? Why?

Answer 317

Those who have continued symptoms and exacerbations despite dual therapy with a LAMA/LABA. This is because ICS are associated with increased risk of pneumonia in COPD patients, so the risks vs benefits need to be carefully weighed up

Question 318

True or false? All patients with suspected asthma/COPD overlap should be referred for Specialist management

Answer 318

True - these patients have more rapid disease progression and require specialist management, the evidence is limited and approaches differ

Question 319

Patients with COPD have increased risk of which other major medical conditions? Name at least 4

Answer 319

CVD, diabetes, osteoporosis, anxiety with panic attacks and depression, pulmonary hypertension and cor pulmonale

Question 320

Cor pulmonale should be considered in a patient with COPD who has any of which 4 features?

Answer 320

Peripheral oedema, raised JVP, systolic parasternal heave, loud pulmonary second heart sound

Question 321

How is exacerbation of COPD characterised clinically?

Answer 321

By an acute worsening of symptoms, beyond normal day-to-day variations including: increase dyspnoea, reduced exercise tolerance, tachypnoea, increased cough frequency, increased sputum volume or purulence, fever, right heart failure manifesting as ankle oedema

Question 322

List at least 4 triggers for COPD exacerbations

Answer 322

Viral and bacterial infections, environmental pollutants, heart failure and PE, pscyhosocial stressors

Question 323

What is the dose of salbutamol in COPD exacerbation?

Answer 323

8 puffs (or 2.5mg to 5mg if nebulised)

Question 324

True or false? A COPD exacerbation that does not fully resolve with salbutamol may improve with the addition of ipratropium

Answer 324

True.

Question 325

Which treatment is recommended for COPD exacerbation that does not respond sufficiently to inhaled bronchodilators?

Answer 325

5 day course of systemic steroids (30 - 50mg)

Question 326

Antibiotics should only be used in COPD exacerbation if all of which 3 features are present?

Answer 326

Increased sputum purulene, increased sputum volume or change i colour, fever

Question 327

What treatment is recommended for patients with COPD exacerbation who have hypercapnic respiratory failure and acidosis?

Answer 327

NIV

Question 328

In what timeframe should patients see their GP for review after being discharged from hospital with asthma and COPD exacerbations, respectively?

Answer 328

Asthma 3 days, COPD 7 days

Question 329

The duration of a COPD exacerbation is related to which other factor?

Answer 329

The severity of the underlying COPD (for mild COPD, exacerbations can last 7-10 days, for more moderate or severe underlying disease can last weeks)

Question 330

Explain why the doses of amoxicillin and doxycyclin used in the treatment of COPD exacerbation (presuming indicated) are smaller than those used for CAP

Answer 330

Because the aim of Abx in COPD is to hasten recovery rather than eradicate the bacteria, since most COPD patients will be colonised.

Question 331

State the appropriate antibiotic treatment in exacerbation of COPD when indicated

Answer 331

Always oral, whether in community or hospital. Amoxicillin 500mg 8 hourly for 5 days (or 1g 12 hourly if BD dosing is more convenient) OR doxycyclin 100mg daily for 5 days.

Question 332

What does COPDX stand for?

Answer 332

C - case finding and confirm diagnosis. O - Optimise function. P - prevent deterioration. D - develop a plan of care. X - manage eXacerbations

Question 333

What are some of the recommendations in the ‘O’ of COPDX

Answer 333

Optimise function - relates to optimising pharmacotherapy in stepwise approach, checking adherene and technique, referring for pulmonary rehab and advising about exercise, managing comorbid conditions and considering pall care early

Question 334

What are some of the recommendations in the ‘P’ of COPDX

Answer 334

Prevent deterioration - stop smoking, prevent eacerbations, vaccination, consider mucolytics, consider long term O2 therapy for survival benefit in hypoxic patients

Question 335

What are some of the recommendations in the ‘D’ of COPDX

Answer 335

Develop a plan of care - anticipate wide range of needs, consider multiD input and self-management support as well as community groups and services

Question 336

What are some of the recommendations in the ‘E’ of COPDX

Answer 336

Manage exacerbations - early diagnosis and treatment to prevent hospital admission and progression, multiD care may assist in home management, use NIV for patients with rising PaCO2 levels, consider pulmonary rehab at any time, ensure comprehensive follow up

Question 337

What is the first step in the diagnosis of COPD?

Answer 337

Comprehensive history and examination

Question 338

Which test is useful for determining the impact of COPD on symptoms and wellbeing?

Answer 338

CAT - COPD assessment test

Question 339

What are the 5 most prevalent comorbidities in patients with COPD?

Answer 339

Hyperglycaemia, atherosclaerosis, hypertension, dyslipidaemia and osteoporosis

Question 340

What is the greatest risk factor for further exacerbation in COPD?

Answer 340

History of exacerbation within the past 12 months

Question 341

What is the recommended course of pneumococcal vaccination in COPD pateints who have never had one prior?

Answer 341

First dose to be given at diagnosis, followed by up to 2 additional doses

Question 342

What is the recommended course of pneumococcal vaccination in COPD patients who have had an age-appropriate first dose?

Answer 342

Give a singe revaccination dose a minimum of 5 years following the first dose

Question 343

What is the clinical definition of hypoxaemia on ABG?

Answer 343

Pa02 <55, or less than 59 with polycythaemia, pulmonary hypertension or right heart failure

Question 344

What is the definition of ILD?

Answer 344

Heterogenous group of disorders that are characterised by varying degrees of fibrosis and inflammation in lung parenchyma

Question 345

True or false? Resting hypoxia is common in ILD

Answer 345

False. Hypoxia with exercise is common, but resting hypoxia is a sign of advanced disease

Question 346

What is the purpose of both inspiratory and expiratory CT series in the investigation of ILD?

Answer 346

Allows for detection of gas trapping or ‘mosaicism’

Question 347

What is considered to be the gold standard for diagnosing ILD

Answer 347

MultiD discussion between an ILD physician, radiologist and pathologist

Question 348

What investigations are done at baseline in the workup of ILD?

Answer 348

CXR, high res CT, pulse oximetry and ABG, connective tissue disease serology, lung function tests inc. CLCO, 6. minute walk test

Question 349

What are the possible findings of ILD on CXR?

Answer 349

Non specific infiltrates

Question 350

What are the possible findings of ILD on high res CT?

Answer 350

Nodules, cysts, ground glass change, honeycomb change, traction bronchiectasis, intralobular septal thickening

Question 351

What are the spirometry findings in ILD?

Answer 351

Low FEV1, low FVC, normal to high FEV1/FVC ratio, reduced lung volumes, reduced DLCO

Question 352

List the 4 major subtypes of ILD

Answer 352

Idiopathic interstitial pneumonias, granulomatous ILD, ILD with known associations, miscellaneous

Question 353

What is different about the pathogenesis of idiopathic pulmonary firosis compared to the other subtypes of ILD?

Answer 353

Seems to arise from fibrosis, whereas others start with inflammation and then fibrosis

Question 354

List at least 4 common comrbid conditions in ILD

Answer 354

GORD, osteoporosis, infections, sleep disordered breathing, pulmonary hypertension

Question 355

List the 3 most common subtypes of non small cell lung cancer

Answer 355

Adenocarcinoma, squamous cell (epidermoid) carcinoma, large cell undifferentiated carcinoma

Question 356

If examination, CXR and spirometry are normal, state the 3 most common diagnosis for chronic cough in adults

Answer 356

Asthma, rhinosinusitis, GORD

Question 357

If examination, CXR and spirometry are normal, state the 2 most common diagnosis for chronic cough in children

Answer 357

Protracted bacterial bronchitis, asthma (if other symptoms present)

Question 358

What cancer is the leading casue of cancer death in Australia?

Answer 358

Lung cancer (the 5th most common cancer overall)

Question 359

Under what conditions can a GP directly order a Medicare rebated sleep study (home or lab) without the patient first neeting a clinical review by a Specialist?

Answer 359

Must have positive OSA screening questionaire (OSA50 greater than or equal to 5 or STOPBANG greater than or equal to 4) AND ESS greater than or equal to 8

Question 360

Which clinical finding would be more consistent with an atypical pneumonia than with a lobar pneumonia? Fever; wheeze; chest pain; tachycardia; cough?

Answer 360

Wheeze

Question 361

The absence of what clinical sign makes pneumonia in a child very unlikely?

Answer 361

Tachypnoea

Question 362

Which is the most likely pathogen to cause pneumonia in a 2 year old child? bordatella pertussis; haemophilus influenzae; respiratory syncitial virus; strep pneumoniae; mycoplasma

Answer 362

RSV - viruss are the most common cause of CAP in children oder than 2 months

Question 363

A 55 yo woman presents with fever, chest pain, increasing SOB and dry cough. PMHx RA, on MTX. She has bibasal inspiratory crackles and CXR shows diffuse infiltrative pattern. What is the most likely diagnosis?

Answer 363

Drug induced pneumonitits

Question 364

True or false? The ESS is a good marker of OSA

Answer 364

False, but it does predict response to treatment

Question 365

Bacterial CAP in children is most commonly caused by which pathogen?

Answer 365

Strep pneumoniae

Question 366

Name the 3 complications of staph pneumonia in children

Answer 366

Empyema, lung abscess, large parapneumonic effusion

Question 367

What is the antibiotic of choice for treating mild and moderate CAP in children?

Answer 367

Amoxicillin 25mg/kg 12 hourly

Question 368

Which antibiotics may be added to amoxicillin for children with CAP where atypical pneumonia is suspected?

Answer 368

Azithromycin 10mg/kg daily, or doxy or clarithro

Question 369

What is the IV antibiotic of choice for children with severe CAP?

Answer 369

Cefotaxine 50mg/kg up to 2g TDS (or ceftriaxone 50mg/kg up to 2g daily)

Question 370

Name at least 3 occupational exposures, aside from cigarette smoking, that are associated with increased risk of lung cancer

Answer 370

Radon, asbestos, diesel exhaust, silica

Question 371

A 27 yo presents with a 3 day history of fever, headache, fatigue and persistent cough. The cough has slowly become worse and is incessant. O/E she appears well and temp is 37.8. CXR shows diffuse bilateral infiltration. Which is the most likely infective organism? Haemophilus, legionalla, mycloplasma, pseudomonas, strep pneumoniae?

Answer 371

Mycoplasma pneumoniae

Question 372

Describe the clinical presentation of mycoplasma pneumoniae

Answer 372

Low grade fever, headache and cough are prominant. May be normal on examiantion in early illness, but rhonchi, rales or wheeze can be seen several days later. CXR findings are usually more striking than examination findings

Question 373

List at least 5 groups of inviduals deemed to be at higher risk of poor outcomes from influenza

Answer 373

Adults > 65 years, pregnant women, people with: (heart disease, down syndrome, obesity > 30 BMI, chronic resp illness, sereve neurological conditionals, immune compromise), ATSI of any age, children 5 or younger, RACF patients, homeless people

Question 374

A 45 year old previously fit farmer presents with SOB, cough, lethargy and fever. O/E he is febrile, mildly tachypnoeic and has crepitations in the left lung base. What is the most likely organism to account for his clinical findings?

Answer 374

Strep pneumonia - for garden variety CAP

Question 375

In pregnant women with suspected PE who also have symptoms and signs of DVT, what is the first recommended investigation?

Answer 375

Compression dupex US - if DVT is confirmed, no further investigation is required and treatment for VTE should continue

Question 376

In pregnant women with suspected PE who do not have symptoms and signs of DVT, what is the next step in investigation?

Answer 376

V/Q scan or CTPA should be performed

Question 377

What is the resting threshold oxygen saturation at room air as measured by pulae iximeter that required supplemental oxygen in flight?

Answer 377

SpO2 < 88%

Question 378

What factors need to be met for a COPD patient to be considered for long term oxygen therapy?

Answer 378

Those with stbale disease and hypoxaemia, who has ceased smoking for at least 1 month and potentially reversible factors are treated

Question 379

Describe the clinical presentation and course of pertussis

Answer 379

Initial catarrhal phase wth insidious onset runny nose, low/absent fever, mild cough. Cough slowly becomes paroxysmal after 1-2 weeks and may end in vomiting, cyanosis and/or insi]piratory whoop. Fever general minimal throughout

Question 380

What are the common symptoms of legionaires pneumonia

Answer 380

Fever, cough, chest pain, breathlessness and diarrhoea

Question 381

What is hypersensitivity pneumonitis?

Answer 381

AKA extrinsix allergic alveolitis - diffuse, granulomatous inflammation of the lung parenchyma and airways in people who have been sensitised by repeated inhalation of organic antigens in dusts (daily or grain products, animal dander etc)

Question 382

Give some examples of hypersensitivity pneumonitis, depending on the source

Answer 382

Farmer’s lung (mouldy hay), bird fanciers lung (avian proteins), cheese workers lung (cheese mould), hot tub lung

Question 383

Describe the presentation of acute hypersensitivity pneumonitis

Answer 383

Start within 4-8 hours of exposure and resolve rapidly. Symptoms similar to pneumonia with dry cough, bibasal inspiratory crackes on auscultation

Question 384

Describe the presentation of subacute hypersensitivity pneumonitis

Answer 384

Insidious onset, productive cough, dyspnoea, fatigue, weight loss, may be a history of recurrent acute pneumonitis

Question 385

What is normall seen on CXR of hypersensitivity pneumonitis

Answer 385

Micronodular opacities in the mid/upper lung fields. If chronic, may see fibrosis with loss of lung volume

Question 386

What is the treatment for hypersensitvitiy pneumonitis?

Answer 386

Avoidance of the allergens, sometimes corticosteroids in severe cases

Question 387

List at least 3 complications of hypersensitivity pneumonitis

Answer 387

Spontaneous pneumothorax, pulmonary fibrosis, COPD, respiratory failure, cor pulmonale

Question 388

How is bronchiectasis characterised both morphologically and clinically?

Answer 388

Morphologically by dilatation of bronchi and bronchioles and clinically by recurrent bronchial infection and chronic cough with sputum. Can also present with fatigue, breathlessness and pleuritic chest pain, with course crackles on auscultation. Can have clubbing

Question 389

What is the pathogenesis of bronchiectasis?

Answer 389

Related to chronic airway infection and inflammation, resulting in airway damage

Question 390

What is the most common cause of bronchiectasis?

Answer 390

Pneumonia, often in childhood

Question 391

List at least 3 common causes and contributors to bronchiectasis, as well as 3 less common/rare causes

Answer 391

Common: severe resp illness, asthma, COPD, CF. Less common include GORD, RT, connective disuse disease, IBD, alpha 1 anti trypsin deficiency

Question 392

Which disease process should always be considered in patients presenting with coarse crepitations, chronic productive cough and recurrent or difficult to treat chest infections?

Answer 392

Bronchiectasis

Question 393

What is the gold standard for diagnosis of bronchiectasis?

Answer 393

High rest CT

Question 394

Antibiotics should only be used in exacerbations of bronchiectasis when all of which 3 criteria are present?

Answer 394

Increased sputum volume or change in viscosity, increased sputum purulence, increased cough (may be associated with wheeze, dyspnoea or haemoptysis)