Respiratory

Question 1

Management of COPD

Answer 1

Stop smoking
Antibiotics and steroid for exacerbations
SABA, INH steroid, LABA, Anticholinergic INH
Flu and pneumococcal vaccines
Oxygen therapy if paO2 less 55 or less 59 and PHTN
Pulmonary rehab
Nutrition
Monitor for depression

Question 2

Management of TB

Answer 2

Isolate
Confirm (3x induced sputums/lymph node or pleural biopsy) culture to confirm organism
CXR and consider CT
Treatment: RIPE (rifampicin, isoniazide, pyrazinamide, ethambutol) 4 for 2 and 2 for 4
Treat latent TB to decrease rates of transmission and decrease risk of active disease progression

Question 3

Management of IPF

Answer 3

Best supportive care
Remove exposure
Manage exacerbations/infections (abx/?steroids)
Vaccinations
Oxygen therapy
Pulmonary rehab
Opiates
Clinical trials
Lung transplants

Question 4

Management of OSA

Answer 4

Weight loss
Smoking cessation
Stop sedating/offending medications
CPAP
Surgery (tonsillectomy/uvulo...)
Manage BP

Question 5

Management of Pleural Effusion

Answer 5

Diagnosis - pleural aspirate, Lights criteria, cytology, culture
Treat underlying cause
Assess symptoms - only treat if symptomatic
Palliation/advanced care planning if appropriate

Refractory effusions:

• therapeutic thoracocentesis
• pleurodesis - chemical, surgical
• indwelling pleural catheter
• pleuroperitoneal shunting
• pleurectomy

Question 6

Management of Asthma

Answer 6

Confirm diagnosis: PFTs, Peak flow, Flow volume loop, response to bronchodilator, bronchoprovocation testing
Smoking cessation
Avoidance of allergens/occupation
Severity classification: intermittent, persistent (mild, moderate, severe)
Patient education, asthma nurse
Action plan (reduces mortality)
Vaccination

Pharmacological options

• bronchodilators - B agonist, anticholinergic, theophyline
• corticosteriods - inhaled, oral
• anti-leukotriene - montelukast
• anti-IgE monoclonal Ab - omalizumab

Question 7

Management of Lung Transplant.

Answer 7

Immunosuppression: tacrolimus, mycophenolate, glucocorticoids.
Prophylaxis for aspergillus, HSV, CMV, PJP. If bronchiectasis or CF also require antipseudomonal prophylaxis.
Daily FEV1, and if change by 10% see doctor.
Rejection, called bronchiolitis obliterans syndrome. FEV1 change >20%. 50% have normal CXR. Treat with IV Methylprednisolone, and maximise tacrolimus and MMF, also treat with azithromycin and for reflux.
Pneumonia: often gram negative eg enterobacter or pseudomonas, or viral., therefore immunise.
Post transplant associated lymphoproliferative disorder.
Cancer of lung, NHL, Cancer of liver or Kidney.
Screen for and manage Osteoporosis,
Diabetes and Coronary Artery Disease.

Question 8

Management of Cystic Fibrosis.

Answer 8

Aims: preserve lung function, maintain nutrition, prevent complications.
Pancreatic enzyme supplement
Multivitamin
High energy diet
Exercise
Mucolytics, hypertonic saline
Bronchodilators
Chest physiotherapy and postural drainage
Antibiotics, based on induced sputum cultures
Anti-inflammatories eg steroid
Diabetes
Bisphosphonates
Regular follow up 3/12 in specialist clinic
Routine vaccinations incl influenza
Psychosocial care
Ivacaftor