Respirology Flashcards
7 year old girl with persistent cough, wheeze, nighttime cough, worse with activity. FEV1/FVC is 75%, bronchodilator increases her FEV1 by 15%. What do you recommend?
A. Inhaled corticosteroid with SABA PRN
B. Avoid the activities that trigger the symptoms
Inhaled corticosteroids with SABA PRN
Has a diagnosis of asthma: FEV1/FVC < 0.8-0.9
Increased FEV1 by >=12% with bronchodilator
It is uncontrolled: nighttime cough
Needs to be on controller ICS
Would also need to avoid activities that trigger Sx, but this is not enough
16 year old competitive hockey player who had a history of asthma that was asymptomatic for 7 years. Has been having exercise induced symptoms and he’s using ventolin 6x/week before and during games. PFTs show normal FEV1 and FEV1/FVC but he has a positive methacholine challenge. What do you recommend?
A. Low dose inhaled corticosteroid
B. Stop playing high level hockey
C. 5 day course of oral corticosteroids
D. LABA in the morning on the days of the games
Low dose inhaled corticosteroids
Has poor control: Ventolin >4X/wk
(Exercise induced Sx)
- Regular need for a reliever to prevent or treat exercise-induced symptoms indicates suboptimal control and should be included in the weekly limit.
Other answers:
- All triggers should be avoided except exercise should not be discouraged
- LABA to be added to ICS if not full control
- Reserve oral steroids for when fail to respond to SABASs
What is the most likely side effect of inhaled steroids? A. Decreased linear growth. B. Immunosuppression C. Moon facies D. Hypertension
Decreased linear growth
Regular use of ICS at low or medium daily doses is assoc’d with mean reduction of final adult height by 1.2cm
(0.5cm/yr in linear growth velocity, 0.6cm change from baseline height during 1y treatment period)
You are seeing an adolescent male with a history of asthma. He is complaining of worsening asthma symptoms despite compliance with his inhalers. He admits that his group of friends has recently starting vaping and dripping. You advise:
A. Advise him not to be around his friends when they are dripping
B. Advise him there is no harm in the use of e-cigarette products
C. Advise him to not be around his friends when they are using e-cigarette products
D. Advise him not be around his friends when they use e-cigarette products with nicotine
E. He should tell his friends to stop vaping
Advise him not to be around his friends when they are using e-cigarette products
- e-cigarettes produce fine particulates greater than conventional cigarettes. Impair resp function. Worsen pre-existing breathing problems (asthma, bronchitis)
A 7 year old boy with asthma is using ventolin. On your follow up visit, you find out that he uses his ventolin 2 puffs, 3-4 times per week, and has had 2 courses of systemic steroids in the last year. What should be your next course of action?
A. Increase ventolin dose to 4 puffs as needed
B. Add inhaled corticosteroid
C. Add oral prednisone
Add inhaled corticosteroid
Severe asthmatic, tried multiple doses beta agonist and IV steroids with no response what should you do next?
A. One dose of MgSO4
B. INH heliox
C. Aminophylline infusion
One dose of MgSO4
Kid has eczema and has cough with exercise relieved an hour later. Normal FEV. Normal PFT. What do you do to get the diagnosis?
A. Methacholine challenge
B. Exercise with spirometry
Methacholine challenge b/c more sensitive
CTS guidelines say you can do either one
Exercise testing - tester dependent
Do methacholine challenge when patients fail traditional PFT testing, but symptoms are highly suggestive of asthma. Test causes bronchoconstriction
Kid w viral wheezing, worse w URTI
A. Give steroids + ventolin in winter + fall time
Give steroids + ventolin in winter and fall time
If preschooler who is not currently wheezing with >=2 episodes of asthma-like Sx, do therapeutic trials;
- mild, infreq Sx: SABA PRN
- mod-severe, freq Sx (>8X/mo): medium dose ICS x3mo + SABA PRN
If school aged child: make the Dx with PFTs
If mild asthma Sx: start low dose ICS + SABA PRN
Teenager with exercise induced wheezing. Spirometry normal. What is next step?
A. Methacholine challenge
B. Spirometry during exercise
Methacholine challenge
Child with wheezing during exercise. No significant reversibility (80 to 85%) PFTs given. How to further investigate?
A. Exercise challenge
B. Methacholine test?
Methacholin challenge
Teenager with asthma. Using lots of ventolin. What to do next?
A. Verify technique
Verify technique
Reasons for poor control:
- Wrong diagnosis
- Wrong technique
- Poor adherence
- Ongoing exposure to triggers + comorbidities
- Wrong dose
Recurrent wheezing with urti, how to treat?
A. Fluticasone
B. Salbutamol
Depends on what they were on before.
CTS Guidelines: all individuals with asthma should have access to a fast acting bronchodilator for use as needed to treat acute Sx
If preschooler with mild Sx: SABA PRN
If preschooler with moderate Sx (>2 exacerbations): trial of medium dose ICS + SABA PRN
If child >=6yo: do PFTs to diagnose
Consider start ICS
Teen with asthma. Still symptomatic on inhaled fluticasone 125 mcg BID and monteleukast. Uses ventolin QID. Best treatment to address acute and chronic symptoms.
A. Salmeterol and fluticasone (Advair)
B. Formoterol and budesonide (Symbicort)
C. Salmeterol and ciclethisone (sp) (dont know what this is)
Formoterol + budesonide (Symbicort)
Teen on Low dose ICS+LTRA. Add LABA
Both Advair + Symbicort are ICS + LABA
- Symbicort: >=12yo (>=6yo practically)
- Advair: >=4yo
But SMART = Symbicort for maintenance and acute relief therapy
- RCT that looked at symbicort vs Advair in >=16yo
- Symbicort has more evidence for potential to use as reliever medication in addition to maintenance
15 yo boy with poorly controlled chronic asthma. Fluticasone 125 mcg bid, on leukotriene antagonist, and still requires 2 ventolin puffs a day. What management should we do now?
A. Fluticasone and salmeterol → Advair
B. Budesonide and formoterol → Symbicort
C. Ciclesonide and salbuterol → not appropiate b/c salbuterol is a SABA
D. Budesonide + ipatropium bromide + salmeterol
Budesonide + fomoterol
> =12yo. Fluticasone low dose, LTRA. Add LABA
Both Advair + Symbicort are ICS + LABA
- Symbicort: >=12yo (>=6yo practically)
- Advair: >=4yo
But SMART = Symbicort for maintenance and acute relief therapy
- RCT that looked at symbicort vs Advair in >=16yo
- Symbicort has more evidence for potential to use as reliever medication in addition to maintenance
Proven therapy in a kid with recurrent viral wheezing?
A. Ventolin
B. Fluticisone X 3 weeks
Ventolin
2 yo child with recurrent viral wheezing. What is proven therapy?
A. Ventolin PRN
B. Prednisone 5 days
C. Fluticasone 3 weeks
Ventolin PRN
Preschool with recurrent (>=2) episodes of asthma-like Sx
If currently wheezing
- Start therapeutic trial of either SABA (if mild exacerbation) or SABA + OCS (if moderate to severe exacerbation)
- Direct observation of improvement by MD or trained HCP confirms asthma Dx
If currently NO wheezing
- If has freq Sx (>=8d/mo w asthma-like Sx) or >=1 mod-severe asthma-like exacerbation: therapeutic trial of medium dose ICS for 3mo with PRN SABA
- If <8d/mo of Sx or mild asthma-like Sx or mild asthma-like exacerbation (last hrs to a few days, no rescue OCS or hospital admission): therapeutic trial of PRNA SABA x3mo
Other answers:
- Prednisone can potentially help with an exacerbation, but not for asthma control
- Medium dose fluticasone should be trialed for 3mo, not 3wks
What is the best measure to decrease the likelihood of asthma in child?
A. Breastfeeding
B. Avoid second hand smoke
C. Elimination of environmental allergens
Breastfeeding
Adolescent female receives inhaler fluticasone BID and ventolin via MDI spacer TID. Her PFT shows FEV1 65% and improves by 20% with bronchodilators. What should be done now?
A. Check technique and compliance
B. Increase inhaled corticosteroid dose
Check technique and compliance
CTS guidelines: Need to check before increasing along the pyramid: 1. Sx control 2. Correct diagnosis via spirometry/PEF 3. Correct inhaler technique 4. Adherence 5. Persistent exposure to triggers 6. Comorbidities
What will predict the persistence of asthma in adulthood?
A. Severe RSV pneumonia with intubation
B. Allergic rhinitis
Allergic rhinitis
Atopic wheezers are more likely to have persistent Sx into adulthood
CPS Position Statement on Asthma in Preschoolers:
Wheezing in early childhood associated with decreased lung function at 6yo (FEV1 is 10% lower than healthy peers) that generally persists until adulthood
Which of the following is the most helpful measure to decrease risk of asthma?
A. Dust mite covers
B. Elimination of environmental smoke exposure
C. Removing pets from the home
D. Breastfeeding
Eliminate smoke exposure
Nelsons; avoidance of environmental tobacco smoke (beginning prenatally), prolonged breastfeeding (>4 months), an active lifestyle and healthy diet - might reduce the likelihood of asthma development
Child with BMI 25. Cough and shortness of breath with gym class. Dad had allergic rhinitis and boy has history of mild eczema. FVC 80%. With inhaler, FEV1 increases to 87% and FVC to 85%. Treatment? A. Salbutamol prior to exercise B. Steroid inhaler C. Needs conditioning D. Steroids PO
? Needs conditions
Not sure what the pre-bronchodilator FEV1 was
Consider methacholine or exercise challenge test
Teen with asthma , what would be an indicator of poor control:
A. Using ventolin 2/week for wheezing
B. Using ventolin 2/week for exercise
C. Using ventolin 2/week for night cough
D. Using ventolin with upper respiratory tract infections
Ventolin 2x/wk for night cough
Poor control of asthma
A. Use of ventolin 2 days/wk
B. Use of ventolin 2 nights/wk
Use of ventolin 2 nights/wk
8 yo with BMI 25, SOB with exertion. Dad with allergic rhinitis. Patient has mild eczema. PFTs show. FVC 80%, FEV1 84% → 87% with bronchodilator and FVC to 85%. What is the treatment? A. BID fluticasone B. Salbutamol prior to exercise C. Montelukast D. Physical training
Physical training
Does not meet asthma criteria
Calculation for change in FEV1 with bronchodilator: (87 - 84)/84 * 100 = 3.5% increase
What is the best indicator for mortality in asthma A. Previous intubation B. Previous oral steroids C. Family history D. History of atopy
Previous intubation
What are RFs for ICU admission and death?
- Previous life-threatening events
- Admissions to ICU
- Intubation
- Deterioration while already on systemic steroids
What are RFs for asthma morbidity + mortality (Nelson’s)
A. Biologic
1. Previous severe asthma exacerbation (ICU admission, intubation for asthma)
2. Sudden asphyxia episodes (resp failure, arrest)
3. >=2 hospitalizations for asthma in past year
4. >=3 ED visits for asthma in past year
5. Using >2 canisters of SABA/mo
B. Environmental
- Environmental tobacco smoke exposure
- Allergen exposure
- Air pollution exposure
C. Economic + Psychosocial
- Poverty
- Crowding
- Low SES
- Poor access to medical care
- Poor perception of asthma Sx
6 year old girl with otitis media and sinusitis, found to have bilateral wheezes and crackles on exam as well as clubbing. She also has cobblestoning of the posterior oropharynx. Sweat chloride is negative. Which of the following tests would reveal the diagnosis?
A. CT sinuses
B. Electron microscopy of respiratory mucosa
C. Immunoglobulins
D. Alpha 1 anti-trypsin levels (serum)
? electron microscopy of respiratory mucosa
Primary ciliary dyskinesia
Note: cobbelstoning of posterior pharynx mucosa = allergic rhinitis
A child comes in with wheezing for the last few weeks. It started after playing at a friend’s house. She has not responded to corticosteroids or antibiotics. Her CXR is normal and she is not in respiratory distress. What is the next best management. A. Bronchoscopy B. Racemic epinephrine C. Ventolin and steroids D. Chest CT E. Neck X-ray
Bronchoscopy to r/o foreign body
- *History is the most important factor in determining need for bronchoscopy
- Never ignore positive Hx (choking/coughing followed by wheezing)
Bronchiectasis-5 yo with productive cough day and night, wheeze, crackles, clubbing, how will you get the diagnosis?
A. Immunoglobulins
B. A1AT
C. Biopsy and microscopy → assuming nasal cilliary Bx
D. CT sinuses
Electron microscopy of nasal ciliary Bx
Note in this case, if CF was an option, would consider sweat chloride
Patient presents with diffuse wheezing and crackles. He is well grown. He has had a negative sweat chloride. What test would help with his diagnosis?
A. CT chest
B. Ig
C. Bronchoscopy with tracheal mucosal biopsy
Bronchoscopy with tracheal mucosal biopsy
Transmission electron microscopy is gold standard
Can get sample from NP or endobronchial
15 year old girl with SOB, no wheeze and no response to puffers. What would give you the strongest support for vocal cord dysfunction?
A. Normal oxygen saturation
B. Vocal cord abduction with inspiration
C. Truncated inspiratory loop on spirometry
D. Normal chest xray
Truncated inspiratory loop
Vocal cord abduction with inspiration is NORMAL
VCD: inappropriate and involuntary ADDuction of vocal cords during inspiration + sometimes during expiration
3 week old baby, admitted with bronchiolitis. Mildly tachypneic, and retractions on exam. Requiring O2 0.5L/min. Day 2 of admission, febrile 39C. Exam otherwise unchanged. What is cause for fever? A. GBS B. Strep pneumo C. GAS D. RSV
RSV
6 m.o baby with bronchiolitis symptoms. What is the best evidence supporting treatment: A. Oral dexamethasone B. Oxygen C. Nebulized epinephrine D. Nebulized salbutamol
Oxygen
It is the beginning of RSV season; who qualifies for RSV prophylaxis?
A. 2mo with cystic fibrosis
B. 4 mo ex 31+6 wk without chronic lung disease
C. 9 mo ex 33+6 wk with chronic lung disease requiring home O2
D. 15 mo old with congenital heart disease, now corrected
9mo ex 33+6wk GA with CLD requiring home O2
Because <12mo at start of RSV season with CLD requiring home O2
Other indications: 2. <12mo with hemodynamically significant CHD (O2 diuretics, bronchodilators, O2) 3. <6mo and <30wk 4. <6mo and <36wk in remote area 5. <6mo and term Inuit in remote area 6. Consider in <24mo a) Home O2 (or just weaned off in past 3mo) b) Prolonged hospitalization for resp illness c)T21 d) CF e) Severely immunocompromised
A 2 month old child is seen with a 3-4 day history of viral URTI symptoms. Now, has progressively increasing work of breathing. RR is 65, O2 sat is 91% on room air. On auscultation there is diffuse wheezing. Of the following treatment modalities, which has been proven effective in this disorder? A. Oxygen plus nebulized Ventolin B. Oxygen plus nebulized epinephrine C. Oxygen plus corticosteroids D. Humidified oxygen alone
Humidified O2 alone
RSV bronchiolitis
Wheezing toddler with URTI symptoms. Which is a proven therapy? A. O2 B. Racemic epi C. IV steroids D. Bronchodilators
O2
A one-month old baby presents with tachypnea, fever and a CXR showing bilateral interstitial infiltrates. There is significant wheezing on physical examination. O2 sats are 91%. Which therapy has been shown by evidence to give definite benefit? A. Salbutamol B. Racemic epinephrine C. Oxygen D. Prednisone
Oxygen
4 year old with CF, most likely deficiency: A. Iron B. Calcium C. Vitamin D D. Zinc
Vitamin D
Pancreatic insufficiency = fat soluble vitamins = ADEK
Vit A = eyes (night blindness, dryness of cornea + conjunctiva), follicular hyperkeratosis
Vit D = nutritional rickets, osteopenia, osteoporosis
Vit E = peripheral neuropathy, myopathy, hemolysis
Vit K = coagulopathy
Young child with 2 episodes of rectal prolapse. A. Manometry B. Rectal bx C. Sweat chloride D. Barium enema
Sweat chloride
Due to steatorrhea, malnutrition, repetitive cough.
Usually improves with adequate pancreatic enzyme replacement, stool softener.
