week 2

Question 1

does pulmonary rehabilitation improve COPD

Answer 1

it can! There is excellent evidence for the impact of pulmonary rehab on COPD outcomes such as days spent in hospital and quality of life, and good evidence that it improves survival.

Question 2

where does centriacinar emphysema begin

Answer 2

centri-acinar emphysema begins with dilatation of the respiratory bronchiole, and then progresses to loss of alveolar tissue.

Question 3

is chronic hypoxaemia a feature of bronchial asthma

Answer 3

no, bronchial asthma is variable and reversible, without reduced respiratory drive and loss of alveolar area, so there is no chronic hypoxaemia. Oxygen levels should be normal.

Question 4

what is tracheal tug

Answer 4

a sign of respiratory distress in children.abdominal breathing, subcostal recession, intercostal recession and head bobbing are all signs of respiratory distress in children, and result from trying to draw breath in through an obstructed airway.

Question 5

does fluticasone have more severe side effects than beclomethasone

Answer 5

fluticasone is more potent and has a higher risk of serious side effects.

Question 6

how does washing a spacer help improve its efficacy

Answer 6

washing the spacer device leaves a coating of detergent, which will decrease the static charge. This means the drug is less likely to stick to the spacer, and increases drug delivery to the lungs.

Question 7

how do humidifiers affect asthma control

Answer 7

no evidence to suggest they have nay effect

Question 8

what should a child under the age of 5 who has just been diagnosed with asthma and is symtomatic more than 3 times a week be started on

Answer 8

the initial preventer medication for under 5s is a LRTA. For children over 5, it is a very low dose inhaled corticosteroid.

Question 9

is spirometry required to diagnose chronic bronchitis

Answer 9

it is a clinical diagnosis, meaning there are no specific tests for chronic bronchitis.

Question 10

can COPD be the cause of finger clubbing

Answer 10

NO!

Question 11

is spirometry required to diagnose COPD

Answer 11

unlike asthma, the diagnosis of COPD requires both typical symptoms and history AND typical spirometry showing airflow obstruction. Spirometry is performed pre- and post-bronchodilator therapy, to demonstrate non-reversible (or partially reversible) obstruction.

Question 12

what is asymmetrical chest expansion indicative of

Answer 12

asymmetrical chest expansion is suggestive of lobar collapse or pleural effusion, and is not typically a finding in the asthmatic chest. Chest examination is usually normal in the clinic.

Question 13

why should people with COPD not be treated with high flow oxygen

Answer 13

some people with advanced COPD have chronically elevated CO2 levels, which means the central chemoreceptors that detect CO2 and control the respiratory drive are desensitised and do not work. These people therefore rely on their less sensitive peripheral chemoreceptors to detect oxygen levels and generate a respiratory drive. Over-oxygenating these people can “switch off” the peripheral chemoreceptors and make their respiratory failure worse. People with severe COPD should be oxygenated carefully, with the lowest flow required to achieve acceptable oxygen saturation. In people with known Type 2 respiratory failure, this should be about 88-92%.

Question 14

do new goblet cells appear in chronic bronchitis

Answer 14

goblet cells produce mucus. Chronic inflammation leads to new goblet cells appearing in small airways, and an increase in the number of goblet cells in larger airways.

Question 15

can a patient still have asthma with normal spirometry

Answer 15

yes, variability is a feature of asthma. Normal spirometry cannot rule out intermittent airway obstruction.

Question 16

how shoulds steroids be given during an acute asthma attack

Answer 16

in an acute asthma attack, steroids should be given orally, or sometimes intravenously.

Question 17

what is the hallmark of obstructed lung disease

Answer 17

reuced FEV1:FVC (less thqn 0.7)

Question 18

how much is height restricted in adults by brown inhalers

Answer 18

height restriction is generally about 0.5-1.0cm.

Question 19

is the airway obstruction in asthma reversible

Answer 19

the obstruction is caused by inflammation and smooth muscle contraction, so can reverse spontaneously or with medication.

Question 20

when is someone eligible for long term oxygen therapy

Answer 20

patients are eligible for LTOT if they have a PaO2 (measured from an arterial blood sample) of <7.3 regardless of additional features. If they have complications of chronic hypoxia such as polycythaemia, pulmonary hypertension, peripheral oedema or nocturnal worsening of hypoxia, LTOT is offered sooner, at a PaO2 of <8.

Question 21

what type of drug is ipatropium

Answer 21

ipratropium bromide is a muscarinic antagonist. It works by relaxing the smooth muscle of the airways.

Question 22

is flapping tremor a sign of hypoxia

Answer 22

no, flapping tremor is a sign of hypercapnia – carbon dioxide retention.

Question 23

what is type 2 respiratory failure a sign of

Answer 23

COPD, An easy way to remember type 1 vs type 2 respiratory failure is that in type 2 failure, the movement of 2 gases is impaired. In type 1 respiratory failure, there is a failure of oxygenation, but ventilation is adequate to clear CO2 (remember that CO2 dissolves much more readily than oxygen). In type 2 respiratory failure, ventilation is impaired to the point that not only does oxygenation fail, but CO2 isn’t being cleared, and CO2 levels rise. In COPD, this is a sign of advanced disease.

Question 24

what does hypoxia lead to

Answer 24

constriction of pulmonary arterioles. When the oxygen tension in the alveoli drops, the vessels constrict, as there is no benefit to sending blood where there is no oxygen.

Question 25

what is terbutaline

Answer 25

Terbutaline is a short-acting beta agonist used as a reliever medication in asthma.

Question 26

what should co gas transfer be like in asthma

Answer 26

In asthma it should be normal or slightly increased.

Question 27

what is respiratory failure in COPD due to

Answer 27

respiratory failure in COPD is due to matched defect in ventilation and perfusion. Remember that oxygenation will be impaired in any situation where blood is not getting to the alveoli (perfusion) or air is not getting to the alveoli (ventilation). In COPD, both are affected.

Question 28

is spirometry required to diagnose asthma in adults

Answer 28

no, s in children, asthma can be diagnosed based on a highly suggestive history, and confirmed by a good response to treatment.

Question 29

what is the initial treatment of asthma in adults

Answer 29

Initial treatment of asthma in adults is with a low-dose inhaled corticosteroid.

Question 29

what uis cultural competence

Answer 29

the consideration of the diversity of cultural factors (such as language, beliefs, preferences) that are important to your patients. This results in you approaching each patient in a manner that is tailored to them and sensitive to these cultural factors, rather than treating all patients exactly the same.

Question 30

is female sex a risk factor for COPD

Answer 30

yes, although the prevalence of COPD among males has historically been higher than that among females (due to a higher prevalence of smoking), a female smoker is more likely to develop COPD than a male smoker.

Question 31

does hypoxia increase the blood pressure in the lungs in COPD

Answer 31

hypoxia leads to a reflex constriction of blood vessels in the lungs. This increases the vascular resistance, meaning the right side of the heart has to work harder, and the blood pressure rises. This is called pulmonary hypertension.

Question 32

describe FeNO in asthma

Answer 32

FeNO works like a breathalyser for airway inflammation. A high degree of inflammation will lead to a high FeNO, which would be suggestive of asthma.

Question 33

what can a deficiency in alpha-1-antitrypsin lead to

Answer 33

alpha-1 antitrypsin is an enzyme which breaks down other enzymes that break down alveolar tissue. A deficiency of this enzyme tips the balance towards tissue destruction, and can lead to emphysema

Question 34

what is the next step for a child over five on a very low dose of ICS

Answer 34

the BTS/SIGN guidelines would recommend a long-acting beta agonist (LABA) as the next step

Question 35

what causes asthma and allergies

Answer 35

an underlying abnormality in the epithelium

Question 36

what is emphysema

Answer 36

emphysema is the increase in size of the airspaces that are distal to the terminal bronchioles (i.e. the respiratory bronchioles and alveoli). This can be due to dilatation or destruction of their walls, and causes obstruction through air trapping.

Question 37

when are low dose inhaled steroids used in asthma

Answer 37

very low dose inhaled steroids are the initial treatment for paediatric asthma. Oral steroids are only used by specialists in treatment-resistant asthma.

Question 38

what is the aim when treating childhood asthma

Answer 38

aiming for minimal symptoms and good quality of life.

Question 39

what is peripheral eosonophilia suggestive of

Answer 39

while a peripheral eosinophilia may be suggestive of atopy (remember this is the cluster of conditions including asthma, eczema, hayfever, allergic rhinitis and other allergies)

Question 40

what is normal FEV1:FVC

Answer 40

0.7-0.8

Question 41

what happens to pCO2 in moderate or severe exacerbations of asthma

Answer 41

In moderate or severe exacerbations of asthma, the respiratory rate goes up, so you would expect more CO2 to be blown off, therefore the pCO2 (measurement of the amount of CO2 dissolved in the blood, shown on a blood gas analysis) should be LOW. If a patient is having an acute asthma attack with a high respiratory rate and their pCO2 is “normal”, this means they are not ventilating adequately, and this is an indication that they require specialist input urgently as their asthma is life-threatening.

Question 42

what are the majority of exacerbations of COPD

Answer 42

viral

Question 43

when is hyperinflation present

Answer 43

if more than 6 ribs are visible anteriorly, or 10 ribs posteriorly.

Question 44

where does smokimg tend to cause emphysema

Answer 44

at the apex of the lungs

Question 45

what is omalizumab

Answer 45

a specialist treatment, and is termed a “biologic” because it is an antibody. It specifically targets IgE (an antibody involved in the allergy response), compared to e.g. prednisolone which has a much more generalised anti-inflammatory action.

Question 46

what happens to Hb levels in COPD

Answer 46

COPD can cause high haemoglobin due to chronic hypoxia. This is because the body detects the low oxygen levels and attempts to improve oxygenation by making more haemoglobin, a state called polycythaemia.