Respiratory Treatment Pathways

Question 1

What would you do with a primary pneumothorax that is causing dyspnoea or has a rim of air >2cm on CXR?

Answer 1

Aspirate it with a cannula in the 2nd intercostal space mid-clavicular line.

Question 2

What would you do if you aspirated a primary pneumothorax successfully?

Answer 2

Consider discharge and outpatient review in 2-4 weeks.

Question 3

What would you do if the aspiration of a primary pneumothorax was unsuccessful?

Answer 3

Put in a chest drain (5th intercostal space mid-axillary line).

Question 4

What would you do if there was a primary pneumothorax with no dyspnoea that was <2cm on CXR?

Answer 4

Consider discharge and outpatient review in 2-4 weeks.

Question 5

What would you do if there was a secondary pneumothorax causing dyspnoea that was >2cm on CXR?

Answer 5

Put in a chest drain.

Question 6

What would you do if there was a secondary pneumothorax with no dyspnoea that was 1-2cm?

Answer 6

Aspirate it.

Question 7

What would you do if aspiration of a secondary pneumothorax was unsuccessful?

Answer 7

Put in a chest drain.

Question 8

What would you do if aspiration of a secondary pneumothorax was successful?

Answer 8

Admit for 24 hours observations and oxygen.

Question 9

What would you do if a secondary pneumothorax was causing no dyspnoea and was <1cm?

Answer 9

Admit for 24 hours observations and oxygen.

Question 10

What would you do if a person’s COPD was poorly controlled on a SABA or a SAMA?

Answer 10

Check their FEV1.

Question 11

If a person with COPD had an FEV1 of >50%, what would you prescribe them first, and if that was uncontrolled what would you add in?

Answer 11

Either a LABA or a LAMA. If uncontrolled then LAMA+LABA.

Question 12

If a person with COPD had an FEV1 of <50%, what would you prescribe them?

Answer 12

Either LAMA or LABA+ICS.

Question 13

What is the last stage in COPD therapy once other therapies have failed?

Answer 13

LABA+ICS (combo inhaler) and LAMA.

Question 14

What are the steps in treating an acute asthma attack?

Answer 14

O - oxygen (sats between 94-98%).
S - nebulised salbutamol. 
H - IV hydrocortisone or oral prednisolone. 
I - nebulised ipratropium. 
T - IV theophylline/aminophylline.
M- IV magnesium. 
A - anaesthetise and intubate.

Question 15

What are the steps in treating an acute COPD exacerbation?

Answer 15

1. Nebulised high dose salbutamol and ipratropium.
2. 24-48% oxygen titrated against PaO2/PaCO2.
3. IV hydrocortisone or oral prednisolone.
4. Antibiotics (amoxicillin or doxycycline PO) if evidence of infection.
5. Physiotherapy to aide sputum expectoration.
6. Non-invasive ventilation.
7. ITU intubated assisted ventilation only if reversible component e.g. pneumonia.
8. Maybe IV aminophylline if no response to nebulisers and steroids.

Question 16

What is the treatment for TB?

Answer 16

2 months of rifampicin, isoniazid, pyrazinamide, ethambutol. Then 4 months of rifampicin and isoniazid.

Question 17

What would you prescribe in someone with asthma that wasn’t adequately controlled by a SABA?

Answer 17

A low dose ICS.

Question 18

What would you prescribe someone with uncontrolled asthma on a SABA and ICS?

Answer 18

A LABA.

Question 19

What 2 options are there for someone with uncontrolled asthma on a SABA, low dose ICS and LABA?

Answer 19

1. Add in LTRA or SR theophylline or LAMA.

2. Add in medium dose ICS.

Question 20

What are the 2 options for treatment for someone with uncontrolled asthma after adding a 4th drug or increasing ICS dose to medium?

Answer 20

1. Prescribe another of LTRA, SR theophylline or LAMA.

2. Add in high dose ICS.

Question 21

What is the final treatment step in asthma?

Answer 21

Add oral prednisolone daily (consider use of other treatments to minimise steroid use).