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Respiratory Health Flashcards

1
Q

Features of acute severe asthma?

A

RR>25
HR>110
PEFR 33-50% of best or predicted
inability to complete sentences in 1 breath

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2
Q

Objective tests for asthma used in making a diagnosis?

A 
Peak flow variability
Spirometry
FeNO (fractional exhaled nitric oxide) (results of 40 ppb or more is a positive test)-note levels can be lowered by patient's current smoking status
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3
Q

Use of skin prick tests in diagnosing asthma?

A

NOT used in diagnosis

however once diagnosis made, can be used to identify triggers.

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4
Q

Management of suspected occupational asthma in primary care?

A

refer to an occupational asthma specialist

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5
Q

When should a FeNO test be considered in children with suspected asthma?

A

in those aged 5 to 16, FeNO should be offered if there is diagnostic uncertainty after initial assessment AND either normal spirometry or obstructive spirometry with negative bronchodilator reversibility test.

(FeNO 35 or greater in children is positive)

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6
Q

What is the criteria for an obstructive spirometry result?

A

FEV1/FVC ratio of <70%

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7
Q

What is a positive bronchodilator reversibility test in the assessment of asthma in adults?

A

an improvement in FEV1 of 12% or more, together with an increase in volume of 200ml or more

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8
Q

When should peak flow variability be monitored in adults to help diagnose asthma?

A

in those where diagnostic uncertainty after clinical assessment and FeNO and either normal spirometry or obstructive spirometry, reversible airways obstruction but FeNO 39 or less. Consider offering if irreversible obstruction and FeNO 25-39.

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9
Q

What is a positive peak flow variability test in asthma diagnosis?

A

more than 20% variability

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10
Q

What is a positive result in direct bronchial challenge test for adults in testing for asthma?

A

20% fall in FEV1 of 8mg/ml or less

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11
Q

When should patients be reviewed if starting or having medication adjusted for asthma?

A

in 4-8 weeks

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12
Q

Next management step in adults with uncontrolled asthma on SABA+low dose ICS (equal to or less than 400 micrograms of budesonide or equivalent?

A

Add LTRA in addition (montelukast 10mg ON), if sx remain uncontrolled add LABA and consider whether or not to continue LTRA.
If on low dose ICS and LABA +/- LTRA and sx not controlled offer switch to MART-reliever and preventor 1 inhaler (LABA and low dose ICS).

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13
Q

Next management step in adults on MART (low dose ICS+LABA-fast acting, maintenance and reliever) with uncontrolled sx?

A

consider increasing ICS to a moderate maintenance dose (400-800 mcg budesonide or equivalent)
if still not controlled consider increasing ICS to high dose (only as fixed dose regimen with SABA as reliever) OR trial additional drug e.g. montelukast or theophylline OR seek advice from asthma healthcare professional

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14
Q

How to manage children under 5 suspected of having asthma and requiring maintenance therapy?

A

SABA plus 8/52 trial of moderate paediatric dose ICS, stop at 8/52 and review-if sx resolved then reoccurred within 4/52 of stopping ICS then restart ICS at low dose maintenance therapy.
if sx resolved and reoccurred beyond 4/52 of stopping ICS then rpt 8/52 trial.

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15
Q

Management of child under 5 with suspected asthma and uncontrolled sx on low dose ICS (less than or equal to 200mcg budesonide) and LTRA?

A

stop LTRA and refer child to expert

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16
Q

Advice in self management programme for adults with asthma using an ICS as a single inhlaer and asthma control deteriorated?

A

increase ICS for 7 days-consider quadrupling the regular ICS dose

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17
Q

When should a patient’s asthma maintenance therapy be considered to be decreased?

A

when their asthma has been controlled with their current maintenance therapy for at least 3 months.

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18
Q

Objective test to monitor asthma control?

A

spirometry and peak flow (NOT FeNO)

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19
Q

Organisms most commonly implicated in recurrent pulmonary infection in CF patients?

A

Children and early teenagers-staph aureus
(2nd most common is H.influenza)
Late teenagers and adults-P.aeruginosa

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20
Q

PO pred dose for asthma exacerbation in children?

A

<2 years, 10mg pred
2-5 years, 20mg pred
>5 years, 30-40mg pred

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21
Q

When to admit a patient with an asthma attack?

A
  • Any life threatening features
  • If severe asthma attack with any persistent severe sx post bronchodilator therapy
  • If moderate asthma attack with worsening sx post bronchodilator therapy and/or previous near fatal asthma attack
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22
Q

Features that should prompt consideration of admission in a moderate exacerbation of asthma?

A 
age under 18 years
poor treatment adherence
living alone/social isolation
psych problems e.g. alcohol/drug misuse, depression
physical or learning disability
previous severe asthma attack
pregnancy
recent hosp admission
recent nocturnal sx
px in afternoon/evening
exacerbation despite adequate dose of PO steroids prior to presentation
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23
Q

When to f/u patient in GP after asthma attack?

A

within 2 days after attack or admission

24
Q

What HR defines an acute severe asthma attack in children aged >5-12 years?

A

125 or greater

25
What HR defines an acute severe asthma attack in children aged 1-5 years?
140 or greater
26
What RR defines an acute severe asthma attack in children aged >5-12 years?
RR 30 or more
27
What RR defines an acute severe asthma attack in children aged 1-5 years?
RR 40 or more
28
Next pharmacological step in managing stable COPD patient who remains breathless despite using PRN short acting bronchodilators (SABA or SAMA) e.g. salbutamol or ipratropium?
- Add combination therapy with inhaled LAMA and LABA if no features of steroid responsiveness. - If they have asthmatic features or features of steroid responsiveness e.g. PEFR variability, eosinophilia, consider LABA+ICS instead.
29
If COPD patient is on LABA+ICS, when would you offer a LAMA?
- day to day sx continue to adversely impact their QOL or - severe exacerbation (req hosp admission) or - 2 moderate exacerbations within a year
30
If pt on LABA+LAMA for COPD when would you consider adding ICS?
``` severe exacerbation (req hosp admission) or 2 moderate exacerbations within a year ``` if sx adversely impacting daily life on LABA+LAMA but not meeting above criteria consider 3/12 trial of ICS.
31
When to consider prophylactic Abx therapy in COPD? (azithromycin 250mg 3 times a week)?
if don't smoke AND have optimised non-pharm management+inhaled therapies, vaccinations (influenza+pneumococcal) and pulm rehab referral AND 1 or more of: -4 or more exacerbations with sputum production in 1 year -prolonged exacerbations with sputum production -exacerbations resulting in hospitalisation
32
Baseline tests before starting prophylactic azithromycin in COPD?
ECG to rule out QT prolongation LFTs - when starting, must advise patients about risk of hearing loss and tinnitus - must also have a CT chest to exclude bronchiectasis
33
Tx for latent TB infection (dx with mantoux or interferon gamma release assay) ?
3 months of isoniazid (+ pyridoxine) and rifampicin or | 6months of isoniazid
34
Tx for active TB?
6 months of Abx Rifampicin, isoniazid (+pyridoxine), pyrazinamide and ethambutol for 2 months then continue rifampicin and isoniazid for a further 4 months
35
When should LT O2 therapy be considered for patients with COPD?
``` if don't smoke and: -either PaO2 <7.3 when stable (2 or more ABGs 3 weeks apart) OR -PaO2 7.3-<8 and either 1 of: secondary polycythaemia peripheral oedema pulmonary HTN ```
36
Which people despite meeting MRC criteria would be unsuitable for pulmonary rehab?
- unable to walk - unstable angina - recent MI
37
Initial examination/investigations recommended in suspected COPD?
post bronchodilator spirometry (WITHOUT reversibility testing) CXR FBC BMI
38
2ww referral criteria for suspected lung cancer?
age 40 and over with unexplained haemoptysis | CXR findings that suggest lung cancer
39
When should an urgent (within 2wks) CXR be requested to assess for lung cancer?
if age 40 and over with 2 or more of the below unexplained sx or 1 or more of the below unexplained sx if have ever smoked: - SOB - cough - CP - fatigue - weight loss - loss of appetite consider requesting if 40 and over with persistent/recurrent chest infection/cervical or SC lymphadenopathy/thrombocytosis/chest signs consistent with lung ca/clubbing.
40
What is the definition of abnormal neck circumference in the assessment of sleep-disordered breathing?
>43cm in males >40cm in females this is an idea of fat in the neck
41
Investigations for sleep apnoea?
``` sleep study (polysomnography)-gold standard overnight pulse oximetry ```
42
How is the severity of sleep apnoea graded?
Apnoea hypopnoea index (AHI)-number of apnoea and hypopnoea in 1 hr of sleep mild: 5-15 moderate: 15-30 severe: more than 30
43
What can be offered by a sleep clinic for moderate or severe sleep apnoea?
CPAP or BiPAP
44
Tx of mild sleep apnoea?
lifestyle modifications: weight reduction regular exercise, healthy diet, reduce smoking and alcohol sleep in lateral position
45
Who should receive antiviral tx for influenza?
'at risk' patients | give oseltamivir 75mg BD for 5/7 ideally within 48hr of sx onset
46
1st line Abx for acute exacerbation of bronchiectasis?
amoxicillin OR doxycycline OR clarithromycin for 7-14 days
47
Abx for CAP with CURB-65 score of 2 (moderate severity)?
amoxicillin + clarithromycin/erythromycin (if atypicals suspected)
48
From what age should patients be tested for CF related diabetes?
age 10, yearly OGTTs | note HbA1c often low in CF patients so not used for screening
49
1st choice of mucoactive agent for patients with CF who have clinical features of lung disease?
rhDNase reduces frequency of exacerbations and rates of decline in lung function can combine with hypertonic saline nebulisers if above ineffective or not suitable can use mannitol dry powder
50
What is the blood spot at day 5 neonatal screening tested for to screen for cystic fibrosis?
level of immunoreactive trypsin (enzyme produced in the pancreas) if significantly raised, sample is then tested for the most common CF mutations in caucasians.
51
Microbiological management of CF patients who are colonised with pseudomonas aeruginosa?
long term nebulised or inhaled antibiotics e.g. colistimethate (Colistin) or tobramycin. Azithromycin used at specific immunomodulating doses can improve lung function and reduce hosp admissions in patients colonised with pseudomonas.
52
Management of CF patients with positive sputum cultures but asymptomatic?
aggressive management with antibiotics
53
For which complications following asbestos exposure can patients claim?
mesothelioma lung cancer caused by asbestos pleural thickening causing disability asbestosis
54
Indications for hosp admission in exacerbation of COPD?
- SpO2 <90% - severe SOB - inability to cope at home - poor or deteriorating general condition including significant co-morbidity e.g. insulin dependent diabetes, cardiac disease - rapid onset of sx - acute confusion or impaired consciousness - cyanosis - worsening peripheral oedema - new arrhythmia - failure to respond to initial tx - already receiving LTOT - changes on CXR
55
When might you consider co-amoxiclav to treat an infective exacerbation of COPD rather than amoxicllin/doxy/clarithromycin?
if person is at higher risk of tx failure e.g. frequent Abx use, previous or current sputum culture with resistant bacteria, or high risk of developing complications note if pt not responding to 1st line Abx after 2-3 days then sputum culture should be sent all patients should receive PO prednisolone 30mg for 5/7
56
When should patients be f/u after an exacerbation of COPD?
once condition stable e.g. around 6 weeks
57
When is Abx therapy considered in acute bronchitis?
- systemically very unwell - pre existing comorbidities e.g. asthma - raised CRP-20-100-delayed px, >100-immediate px PO doxycycline 1st line, if CI then amoxicillin

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