Respiratory

Question 1

How would you manage a patient with a PE?

Answer 1

Immediate heparinisation, and for high risk patients also give haemodynamic support, respiratory support, exogenous fibrinolytics (streptokinase/tPA), percutaneous catheter directed thrombectomy and surgical pulmonary embolectomy.
After start on a long term anticoagulant eg warfarin. For patients who can’t be safely anti-coagulated, insert an inferior vena cava filter.

Question 2

What drugs are used to treat asthma?

Answer 2

Beta2-agonist - salbutamol short-acting or formoterol long-acting (must be prescribed with an inhaled corticosteroid), for smooth muscle dysfunction.
Steroids - budesonide inhaled or prednisolone oral, for inflammation.

Question 3

How would you manage a patient with asthama?

Answer 3

In a stepwise fashion:
Short acting beta agonist eg salbutamol given the whole time. If using >2 times a week consider step up.
1. Low dose inhaled corticosteroid eg budesonide.
2. Regular low dose inhaled corticosteroid.
3a. Long acting beta agonist eg salmeterol and low dose inhaled corticosteroid (can be combined eg symbicort).
3b. Long acting beta agonist and increased dose inhaled corticosteroid (stop LABA if no effect).
4. Long acting beta agonist and high dose inhaled corticosteroid or add methylxanthines eg aminophylline/leukotriene receptor antagonist eg montelukast/long acting anticholinergics eg tiotropium bromide.
5. Daily oral steroid, high dose inhaled corticosteroid and consider biological therapies eg omalizumab (anti-IgE) and reslizumab (Anti-IL-5).

Question 4

How would you manage a patient with acute severe asthma?

Answer 4

High flow oxygen, nebuliser salbutamol, oral prednisolone at 40mg for 10-14 days. If not responding add nebulised ipratropium bromide, and consider IV magnesium and/or IV aminophylline if no improvement(beware if taking oral theophylline).

Question 5

How would you manage a patient with stable COPD?

Answer 5

Smoking cessation.
Pulmonary rehabilitation.
Bronchodilators (beta2-agonists) eg salbutamol.
Antimuscarinics (long acting anticholinergics) eg ipratropium.
Steroids.
Mucolytics eg carbocysteine.
Methylxanthines eg theophylline.
Supplements and dietician review.
Supportive eg flue vaccine.
Consider long term oxygen therapy and lung volume reduction if appropriate.

Question 6

How would you manage a patient with an acute exacerbation of COPD?

Answer 6

Controlled oxygen therapy - sats 88-92%.
Nebulisers - bronchodilators.
Oral steroids (sometimes IV).
Antibiotics if infective features.
Consider IV aminophylline.
Repeat ABG.
Consider non-invasive ventilation or ITU referral for invasive ventilation if no improvement.

Question 7

How would you manage a patient with bronchiectasis?

Answer 7

Physiotherapy/airways clearance.
Sputum sampling - routine culture and NTM.
Exclude immunodeficiency/treat identifiable causes.
Management plan for infective exacerbations.
Consider long-term therapies for future visits.
Flu vaccine.
Pulmonary rehabilitation if MRC dyspnoea score 3 or above.

Question 8

How would you manage a patient with cystic fibrosis?

Answer 8

Lifestyle advice - eg no smoking, avoid other CF patients, flu vaccine.
Maintain lung health and nutritional state - chest physiotherapy, infection management, BMI, pancreatic status, vitamin status.
Targeted genotype specific therapies.
Manage other comorbidities eg diabetes, liver disease.

Question 9

What drugs are used to treat TB?

Answer 9

Rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months.
Then rifampicin and isoniazid for 4 months.
18 months if CNS TB.

Question 10

What drugs are used to treat multi-drug resistant TB?

Answer 10

Quinolone, aminoglycosides, PAS, cycloserine and ethionamide. For a longer duration.

Question 11

How would you manage a patient with acute bronchitis?

Answer 11

Bronchodilation, physiotherapy, with or without antibiotics.

Question 12

What drugs are used to treat mild-moderate community-acquired pneumonia?

Answer 12

Amoxicillin or doxycycline, or erythromycin or clarithromycin.

Question 13

What drugs are used to treat moderate-severe community-acquired pneumonia?

Answer 13

Needs hospital admission.

Co-amoxiclav and clarithromycin or doxycycline.

Question 14

What drugs are used to treat pneumonia caused by atypical organisms?

Answer 14

Agents that work on protein synthesis:
Macrolides (clarithromycin and erythromycin).
Tetracyclines (doxycycline).

Question 15

What drugs are used to treat hospital-acquired pneumonia?

Answer 15

First-line - co-amoxiclav.

Second line/ITU - pipperacilin/tazobactam or meropenem.

Question 16

What drug is used to treat aspiration pneumonia?

Answer 16

Co-amoxiclav.

Question 17

How would you treat a tension pneumothorax?

Answer 17

Insert a plastic cannula (venflon) into the second intercostal space in the mid-clavicular line.
Then insert a chest drain into the 5th intercostal space in the mid-axillary line.

Question 18

How would you manage a patient with lung cancer?

Answer 18

Surgery (mostly for non-small cell).
Radiotherapy - either radical or palliative.
Combination chemotherapy - curative or for symptom control. Can be adjuvant or neoadjuvant.
Combination chemo-radiotherapy.
Biological targeted therapies eg EGFR.
Palliative care and other supportive treatment.