Respiratory, Smoking and Substances Flashcards
A 56year old man with COPD attends with an exacerbation, not requiring hospital admission. You determine he needs antibiotics, what do you prescribe?
First line any of:
Amoxicillin 500 mg TDS for 5 days.
Doxycycline 200 mg on first day, then 100mg OD for 5-day course in total.
Clarithromycin 500 mg BD for 5 days
If high risk tx failure - co-amox TDS for 5 days/ levofloxacin
(In addition to prednisolone 30mg)
A patient started on prednisolone and doxycycline for an exacerbation of COPD is not better 4 days after starting medications. They do not require hospital admissions, according to NICE what two actions should you take?
Send a sputum sample for culture and susceptibility testing
Offer an alternative first choice antibiotic from different class
A 64 year old man presents with worsening breathless on a background of COPD, name 5 things that would make you consider admission?
Severe symptoms and/ or not coping at home
Confusion
Cyanosis or sats <90%
Already on LTOT
Worsening peripheral oedema
New arrhythmia
What are your main 3 considerations in whether to prescribe antibiotics for COPD exacerbations?
Severity of symptoms (i.e. and change in colour, volume, thickness of sputum)
Risk of complications
Previous sputum results
Risk of resistance/ current prophylaxis (use ABx from different class)
Give an example of when COPD should be clinically suspected?
Patients over 35 with a RF (smoking, occupational exposure) and one of:
- Breathlessness
- Chronic cough
- Regular sputum production
- Wheeze
- Frequent LRTI’s
(Also may have reduced exercise tolerance, weight loss, waking at night, ankle swelling etc.)
How is a diagnosis of COPD made?
Clinical symptoms
+
Post bronchodilator FEV1/FVC <0.7
(Spirometry which shows persistent airflow obstruction)
What is cor pulmonale and name 2 signs?
R sided heart failure secondary to lung disease
- Peripheral oedema
- Raised JVP
What are the steps of the MRC dyspneoa scale?
0- Breathless only with strenous exercise
1- Breathless with fast walk/ up slight hill
2- Slowed/ stopping walk due to breathless
3- Can’t walk 100m due to breathless
4- Breathless with ADL’s/ can’t leave house
A 65year old male presents with breathlessness, you suspect COPD given his smoking history, what other differentials could be considered (5)?
Asthma - Younger onset, nocturnal or variable syx, FHx, atopy, non-smoker
Heart failure - Worse lying flat, hx IHD etc
Lung Ca - Haemoptysis, weight loss, voice change
ILD - Dry cough, occupational exposure
Bronchiectasis - Lots of sputum, frequent infections etc
TB etc..
When should a patient with COPD be considered for LTOT assessment?
Treatment for hypoxia NOT breathlessness
- Sats <92% on air
- FEV1 < 49%
- Cyanosis
- Polycythaemia
(Must be non smoker)
What non-pharmacological interventions should be offered to all COPD patients? (5)
Smoking cessation
Inhaler technique advice
Annual flu vaccine
One off pneumococcal vaccine
Advice on increasing exercise
Referral for pulmonary rehab if MRC 3 or worse
What is first line inhaler treatment for a patient COPD?
If breathless and exercise limitation:
1) PRN SABA
- Use DPI over MDI’s for environment
(Easyhaler salbutamol, bricanyl turbohaler)
Your patient with COPD is on a bricanyl turbohaler (SABA) PRN and still getting symptoms, what is next management step?
No asthmatic or steroid responsive features:
2) Add LABA/ LAMA combo (Anoro ellipta/ ultibro breezhaler)
Asthmatic or steriod responsive features:
2) Add ICS/ LABA combo
(Relvar ellipta, fostair nexthaler)
Your patient with COPD is on a bricanyl turbohaler PRN and an ultibro breezehaler (LABA/LAMA) and still getting symptoms, what is next management step?
Keep SABA (Bricanyl turbohaler)
Switch to an ICS/LAMA/ LABA combo:
- Trelegy Ellipta
- Trimbow nexthaler`
What features of COPD would suggest steroid responsiveness?
FEV1< 50%
Frequent exacerbations (1 or more in last year)
Asthma overlap symptoms
Eosinophils > 100cells/ ml
Your patient with COPD is on a bricanyl turbohaler PRN and an Relvar Ellipta (ICS/ LABA) OD and still getting symptoms, what is next management step?
Keep SABA (Bricanyl turbohaler)
Switch ICS/ LABA to an ICS/LAMA/ LABA combo:
- Trelegy Ellipta
- Trimbow nexthaler`
Your 57year old patient with COPD isn’t tolerating a DPI (Salbutamol Easyhaler) you prescribed, what alternatives could you try?
SABA MDI
- Salamol or Airomir
NOT VENTOLIN (large carbon footprint)
Trial PRN SAMA MDI
- Atrovent
Spiriva inhalers contain which medication?
Tiotriopium
(LAMA)
Give three brand names of LAMA inhalers:
Tiotropium:
- Spiriva (respimat/ handihaler/ DPI)
- Braltus
Glycopyrronium:
- Seebri breezehaler
Give three brand names of ICS inhalers:
Qvar (MDI)
Clenil (MDI)
*Easyhaler budesonide (DPI)
*Pulimicort tubohaler (DPI)
Flixotide (DPI or MDI)
Give three brand names of ICS + LABA combination inhalers:
*Fostair (DPI/ MDI)
*Relvar ellipta (DPI)
Symbicort (DPI/ MDI)
Fobumix (DPI)
Seretide/ seriflo/ sirdupla
Give three brand names of ICS + LABA + LAMA combination inhalers:
*Trelegy ellipta (DPI)
*Trimbow Nexthaler (DPI)
Trimbow (MDI)
Enerzair Breezehaler (DPI)
Give three brand names of LABA + LAMA combination inhalers:
*Ultibro breezehaler (DPI)
*Anoro Ellipta (DPI)
Spiolto Respimat
What is the best resource to objectively test asthma control?
Asthma control test
(5Q’s, adult and child versions)
Takes around 1 min
Score out of 25
How do you interpret the results of the asthma control test?
20-25 = Good control
16-19 = Poor control
<16 = Very poor control
After any change in asthma treatment, when should the patient be re-reviewed?
4-8 weeks
After any step up or step down treatment
If an inhaled ICS is contraindicated or not tolerated, what are 3 alternative preventer medications in asthma?
- LTRA (Montelukast) for children under five years old.
- Sodium cromoglicate (children over 5)
- Nedocromil sodium (children over 5 + adults)
- Theophylline (all ages)
A 36 year old patient is on salbutamol and a low dose ICS. Their asthma control test score is 17. What is the next most appropriate step in management?
17 = poor control
Next step = add in LTRA (i.e. montelukast, 10mg ON)
A 36 year old patient is on salbutamol and a low dose ICS alongside Montelukast 10mg ON which they say helped a bit when started. Their asthma control test score is 15. What is the next most appropriate step in management?
Asthma test score 15 = Very poor control
If on SABA + ICS + LTRA, next step is to add LABA
(Switch ICS to ICS/ LABA combo)
A 36 year old patient is on salbutamol and a low dose ICS/ LABA combo alongside Montelukast 10mg ON. Their asthma control test score is 18 and they say it got slightly better with each step of added treatment. What is the next most appropriate step in management?
Asthma test score 18 = Poor control
Switch to MART therapy (this replaces the salbutamol)
- New regieme would be MART (fostair) + Montelukast
A 36 year old patient is on Fostair nexthaler (MART) alongside Montelukast 10mg ON. Their asthma control test score is 18 and they say it got slightly better with each step of added treatment. What is the next most appropriate step in management?
Fostair nexthaler has low dose ICS
Switch to medium dose ICS
In a patient using MART regular therapy, how many additional PRN doses indicates poor control?
In persons using a MART regime, a persistent requirement for PRN doses of their inhaler more than twice per week indicates poor asthma control and
should prompt a review of therapy.
A 36 year old patient is on a MART therapy with a medium dose ICS, alongside Montelukast 10mg ON. Their asthma control test score is 18. What is the next most appropriate step in management (give 3 options)?
1) Increase ICS dose in MART to high dose steroid
2) Add LAMA (tiotropium) such as Spiriva
3) Add oral theophyline (200mg BD)
Give a brief 7 step overview of asthma management in adults?
1) SABA (salbuatmol)
2) SABA + ICS (low dose)
3) SABA + ICS (low dose) + LTRA
—OR— SABA + ICS(low)/ LABA combo
4) Try alternative option of (3) - if previous step no difference stop it
5) Switch to MART (stop SABA > ICS/ fast acting LABA) +/ LTRA
6) Increase ICS dose from low to med
7) Increase ICS dose to high/ add LAMA (spiriva)/ add theophyline
Asthma diagnosis is based of presence of more than one of which 4 symptoms?
Wheeze, cough, breathlessness, and chest tightness
(Usually diurnal symptoms - worse at night/ early morning)Nam
In addition to peak flow, name two investigations commonly performed for asthma? What is classed as a positive result?
FeNO (Over 40 parts per billion = +ve)
Spirometry (+/- reversibility)
- FEV1/FVC < 70% suggests obstruction
- If obstructive, do bronchodilator reversibility
- FEV1 increase of at least 12% and 200mls is considered +ve
What is the false positive and false negative rates of FeNo?
20% (both)
Can be affected by exposure to steroids
How and when is a peak flow diary performed? What is a positive result?
Measure peak flow at different times of day
- Performed if diagnostic uncertainty post assessment/ FENO/ spiro
A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks is regarded as a positive result:
What is first line investigation for asthma in all symptomatic patients?
Spirometry
- Should be offered to all over 5 years
(FENO where possible for those over 17, and for children in those who spirometry either didn’t show obstruction or showed obstruction but with no reversibility)
What level of eosinophills makes you consider patients can be more or less steroid respsonive?
<0.1 = Unlikely to benefit
> 0.1 = Could benefit, give steroids
>0.3 = Very likely to benefit
What are the classic presenting features of a pancoast tumour?
Horners syndrome + shoulder pain
(Apical lung tumour)
Name 3 causes of horners syndrome?
Apical lung tumours
Lymphadenopathy (all causes)
CVA/ MS/ pituitary tumour
Trauma
Brachial plexus or cervical rib trauma
Carotid dissection
(Multiple more)
What are the simplified indications for Abx and steroids in COPD exacerbations as should be explained to paitents?
Breathlessness = Just steroid
Change in sputum = Just abx
If both w= give both
(both for 5 days)
How do you manage asthma exacerbations in a) mod b) severe c) life threatening in adults?
All - Prednisolone 40mg for 5 days (or if less severe quadruple inhaled ICS)
Mod: Salbutamol via space
Severe: Salbutamol via spacer or nebuliser
LT: Salbutamol + ipatropium via nebuliser
Severe/ LT - Oxygen to keep sats 94-98%
What indications in adults for hospital admission with asthma exacerbation?
History of near fatal attack in past
Mod - If not improving
Severe - If any severe features after initial treatment
Life threatening - all
Lower threshold if evening/ recent admission etc.
How many L/min of oxygen are needed to midst nebuliser solution if driving a neb with oxygen?
Minimum of 6/L min usually (but may need more to treat hypoxia?)
When should patients with asthma be reviewed following hospital admission?
All patients should be reviewed in primary care within 2 days of discharge for asthma review
Name 5 classic symptoms of TB?
Pulmonary:
Cough > 3 weeks
Breathlessness
Haemoptysis (2ww if unexplained)
Systemic: Fever/ weight loss/ night sweats
Non specific: Malaise/ anorexia
How should suspected TB be managed?
Send 3 sputum sampels (at least one early morinng) - for acid fast baccilli
Bloods (FBC/ CRP/ U+E/ LFT) + CXR
Refer all to TB team
Name 5 indicators of COPD according to the GSF framework which would indicate advanced disease?
- At least 3 hospital admissions in last year
- MRC 3 or above (SOB after 100m on level)
- Severe disease (FEV1 < 30% predicted)
- LTOT criteria (PaO2 <7.3kpa)
- R heart failure, cachexia, anorexia
With regard to acute bronchitis/ CAP - how does NICE advise CRP should be used to guide treatment?
CRP less than 20 mg/L — do not routinely offer antibiotics.
CRP 20–100 mg/L — consider a delayed antibiotic prescription.
CRP greater than 100 mg/L — offer antibiotic therapy.
What scoring system is used in CAP to help make decisions about hospital admission need?
CRB-65
C- Confusion
U- Urea over 7 (if known)
R - Resp over 30/min
B- BP <90mmHg
65- Age over 65
If 0 manage at home, 1-2 consider admission, 3 definite admission
Occupational factors are likely to be present in what proportion of asthma cases?
1 in 6
At the time of COPD diagnosis, what investigations do NICE suggest should have happened (4 min)?
Spirometry - for diagnosis
CXR - Exclude other diagnosis
BMI
FBC - Assess for polycthemia/ anaemia
What is the threshold NUMBER of exacerbations per year, if any, after which long-term antibiotics are recommended for treating adult bronchiectasis?
Offer long-term antibiotics for adults with bronchiectasis who have three or more acute exacerbations per year
80% of CAP is due to what organism group?
1st line ABx?
Streptococcal
Amox or doxycycline
Which patients are at risk of under/over diagnosis with spirometry?
Spirometry may under-diagnose younger adults and over-diagnose elderly patients.
What are the management options for primary pneumothroax?
<2cm,not SOB - Watch and wait
Small in patients <50 yrs - Needle aspiration
Large/ over 50/ other complexities - Chest drain
What are the management options for secondary pneumothroax?
All observe in hospital for 24 hours/ supplimental oxygen
Most will need chest drain
LTOT - minimum hours a day? What maximum?
Min 15 hrs per day
Upto 24hrs
Patients should be followed up at 3 months
How do you classify severity of COPD?
If FEV1/FVC is < 0.7, grade on FEV1:
Stage 1, mild — FEV1 > 80%
Stage 2, moderate — FEV1 50–79%
Stage 3, severe — FEV1 30–49%
Stage 4, very severe — FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.
At what age of COPD diagnosis cut off would you consider A1AT testing?
Younger ages
(Generally onset <45yrs)
Alcohol dependance DVLA guidelines:
a) Group 1
b) Group 2
a) Group 1 = 1 year abstinence
b) Group 2 = 3 years abstience
(time until can drive after diagnosis alcohol dependance syndrome)
How do you convert tenazepam dose to diazepam dose?
Divide by 2
What is the best benzo to switch to in order to aid reduction and withdrawal?
How frequently do you reduce?
t is easier to withdraw from long-term benzodiazepine use by switching to diazepam, which has a long half-life and is available in a convenient range of tablet strengths.
Daily dose reduced 10-25% every 2 weeks
20 cigarettes per day is equivalent to smoking how much cannabis with regard to bronchial damage?
ThreeD or four cannabis cigarettes
Delirium tremens is characterised by what features?
How long after alcohol withdrawal does it occur?
It is an acute confusional state associated with tremor and autonomic dysfunction.
Essential feature is that it develops within one week following the cessation of heavy ingestion of alcohol or a reduction in the amount of alcohol ingested.
How long is cannabis detectable in urine for?
Up to 27 days (longest of most drugs)
What is the commonest cause of raised GGT?
An increased BMI.
GGT can be expected to only detect about 1 in 5 cases of heavy drinking.
What is FRAMES?
Brief motivational interviewing tool
F – Feedback on risk and harm
R – Responsibility of the patient to change
A – Advice on how to change consumption
M – Menu of strategies to change behaviour
E – Empathic and non-judgmental manner
S – Self-efficacy to raised confidence to change behaviour
What is the definition of staggered paracetamol overdose? How is it managed?
Ingested over more than one hour
All should have NAC started, stopped if paracetamol levels below treatment line after bloods
How do you calculate units of alcohol?
ABV (as %) x volume in ml / 1000
So 500ml can of 5% larger is:
5*500/1000 = 2.5units
What are the options to aid smoking cessation? (name 3)
Varenicline (best odds of smoking cessation)
Bupropion
Nicotine replacement (don’t combine with above two)
What are first line tx options for opiate detox?
Methadone or buprenorphine should be offered as first-line treatment.
Which is the SINGLE MOST appropriate sampling method to confirm a patient has not used heroin in the past week?
Urine remains the most versatile biological fluid for drug testing and has the advantage of indicating drug use over the past several days.
When should varenicline be started to aid smoking cessation?
Advise the person to stop smoking 7–14 days after starting varenicline.
Name 3 presenting features of wernicke-korsakoff-syndrome?
Vision changes (double or blurred vision, eyelid drooping)
Ataxia/ muscle coordination loss
Loss of memory
Hallucinations
In maintenance treatment of heroin addiction, which substitute therapy has strong evidence to suggest it is more likely to retain patients in treatment?
Methadone
f both drugs are equally suitable, then methadone is still considered ‘gold standard’ by The National Institute for Health and Care Excellence (NICE).
What smoking cessation should be advised in pregnancy?
For women who feel able to stop smoking abruptly without treatment, encourage them to do so
For women who feel able to stop smoking but who are likely to relapse without treatment, offer nicotine replacement therapy
What medication can be used to aid reduction of use z-drugs like zopiclone?
What is the dose equivalent for 7.5mg zopi?
Diazepam
5mg equivalent to 7.5mg zopi
When may skin prick testing be useful in asthma?
If considering allergens related to occupational asthma
(Not triggers like hayfever)
NB: All occupational asthma should be referred to secondary care
How long do patients recieve prednisolone for asthma exacerbations?
a) Adult
b) Child
a) 5 days
b) 3 days
Asthma exacerbation, prednisolone dose cut offs for children?
<2yrs = 10mg
2-5yrs = 20mg
Over 5 years 30-40mg
(3 days)
For non-cystic fibrosis bronchiectasis what is the minimum antibiotic duration in exacerbations?
Which ABx are first line?
7-14days
1st: Amoxicillin, doxycycline
(Clari if pen allergic)
What is the typical latency period between the first exposure to a respiratory sensitiser at work and the FIRST presentation of sensitiser-induced occupational asthma symptoms?
Several months between first exposure and first presentation
Often several years before diagnosis
Which percentage of cases of occupational asthma are caused by sensitiser-induced disease?
Most cases (approximately 90%) of occupational asthma are caused by specific sensitisation to a workplace agent rather than irritant-induced occupational asthma.
A patient presents as someone they lived with had TB. What is the first line investigation?
NICE recommend two step approach
1) Mantoux test followed by interferon-gamma assay if the Mantoux test is positive.
What type of spirometry is recommended to make a COPD diagnosis?
Post-bronchodilator spirometry
Reversability is not needed if COPD suspected and can confuse results
How do you calculate smoking pack years?
Cigarettes per day/ 20
*
Number of years smoked
Cystic fibrosis most common organism:
a) In children
b) In teenagers and adults
a) Staphylococcus aureus then second h.influenza
b) Pseudomonas aeruginosa
Prednisiolone exacerbation doses in adutts for:
a) Asthma
b) COPD
a) 40mg for 5 days
b) 30mg for 5 days
Name 3 factors which increase the risk of long covid?
Older age, high BMI, female sex and asthma
How do you manage CAP based on CRB-65 score?
0 = Amoxicillin 500mg TDS for 5 days
1-2 = Amox 500mg TDS AND clarithromycin 500mg BD for 5 days
3 or more = Co‑amoxiclav with either clarithromycin or erythromycin
You suspect a patient has CAP with a CRB-65 of 0. They are allergic to penicillin. Management?
- What about if pregnany?
If amox 500mg TDS unsuitable options are:
- Doxy 200mg then 100mg BD (total 5/7)
- Clarithromycin 500mg BD 5/7
If pregnant: Erythromycin 500mg QDS for 5/7
What should patients with CAP be advised RE symptom length of:
a) Fever
b) Chest pain
c) Cough and breathlessness
d) Fatigue
a) Within a week
b) Within 4 weeks
c) Vastly improved 6 weeks - possibly up to 3 months
d) Can last up to 6 months
Why are LAMA not recommended in asthma?
Onset of action too slow
Which single management option should all patients with bronchietasis recieve?
Airway clearance techniques
How do you manage asympatomatic positive sputum cultures in patients with cystic fibrosis?
All CF patients should have fairly regular sputum cultures
Positive cultures should prompt aggressive management with antibiotics, irrespective of whether or not clinical symptoms are present.
What is the most evidence based ‘alternative’ treatment for asthma management?
Behavioural programmes centred on breathing exercises such as the Buteyko method has been shown to improve asthma symptoms, quality of life and reduce bronchodilator requirement in adults with asthma.
How should hospital admission decision in CAP be guided by CRB-65?
0 - Keep at home
1-2 - Consider admission
3 - Admit
Most common presenting syx of lung cancer?
Cough
Followed by haemoptysis
Name 3 groups in whom asthma is underdiagnosed?
Female gender
Smoking (both current smoking and passive exposure)
Low socioeconomic status/ family problems
Low physical activity/ raised BMI
Some ethnicities
Name 3 indications for emergency resp admission?
Signs SVC obstruction
Life threatening asthma/ COPD
Stridor
Sleep apnea - DVLA rules? (G1 and G2)?
Need to inform DVLA, need medical proof of improval in sleepiness, control of syx etc
Group 1 - Review every 3 years
Group 2- Review every year
How long off driving post CABG?
4 weeks
Don’t need to inform DVLA
When does angina require DVLA need to be notified?
If symptoms at rest
Otherwise don’t need to inform DVLA
When does heart failure require DVLA restriction?
When NYHA IV (3)
(Unable to carry out activity wth discomfort)
Need to inform DVLA
Succesful catheter ablation for arrythemia, how long no driving?
2 days
Pacemaker insertion, how long no driving?
DVLA notification?
7 days
MUST inform DVLA
Stroke DVLA requirements?
No driving for 1 month
Only need to tell DVLA if residual deficit
Name 3 one week no driving indications?
Pacemaker
Angioplasty
PCI
Name 3 four week no driving indications?
Unsuccesful angioplasty
CABG
Heart valve surgery
Any MI which didn’t have PCI
T2DM with metformin and diet - DVLA restrictions for G1 and G2
None
T2DM on any medication other than metformin - DVLA requirements G1 and G2?
G1: No restriction as long as no more than one hypo in 12 months that needed helps
Group 2: Above + full hypo awareness and monitor BM’s twice daily
Patients on insulin - group 1 driving requirements?
Review licence every 1-3 years
No more than one hypo in 12 months
Full hypo awareness
BM monitoring 2 hours before and every 2 hours when driving
Patients on insulin - group 2 driving requirements?
Annual licence
All group 1 plus annual review by diabetes consultant - may also need to fill D2 form
Parkinsons/ MS/ chronic conditions - DVLA rules?
Advise them to contact for DVLA and arrange for assessments
Epilepsy - how defined by the DVLA?
2 or more unprovoked seizures over perioid greater than 24 hours
