Week 2 formative quiz questions

Question 1

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

Answer 1

True – it is now known that inhaled steroids are the most effective initial treatment, and are given as a trial to assist in the diagnosis of asthma.

Question 2

Fluticasone can have more severe side effects than beclomethasone.

Answer 2

True – both are steroids, but fluticasone is more potent and has a higher risk of serious side effects.

Question 3

In spirometry, an FEV1:FVC of 0.5 would be considered obstructive.

Answer 3

True – normal FEV1:FVC is about 0.7-0.8.

Question 4

Peripheral eosinophilia is not diagnostic of asthma.

Answer 4

True – 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), it’s important to remember that there is NO diagnostic test for asthma. Diagnosis is primarily from the history, and some tests are useful to help you gather additional information.

Question 5

People with an acute exacerbation of COPD should always be treated with the highest flow of oxygen available.

Answer 5

False – 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 6

When managing childhood asthma, the aim is for normalisation of spirometry.

Answer 6

False – treatment should be patient-centred, aiming for minimal symptoms and good quality of life.

Question 7

Pharmacological treatments (i.e. inhalers) give the best value for money in terms of improvement in quality of life for patients with COPD.

Answer 7

False – the best value for money in QALY (quality-adjusted life-years) is from flu vaccination, smoking cessation and pulmonary rehabilitation. Non-pharmacological interventions in COPD are very effective and very important.

Question 8

The initial treatment for asthma in children over 5 is very low dose oral steroids.

Answer 8

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

Question 9

The prevalence of COPD is increasing, but the incidence is decreasing.

Answer 9

True – remember that “prevalence” refers to the total number of people with a condition at any given moment, while “incidence” refers to the rate of new diagnoses.

Question 10

Spirometry is required to diagnose COPD.

Answer 10

True – 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 11

Inhaled steroids can be used to diagnose childhood asthma.

Answer 11

True – inhaled steroids are used to treat asthma, so are often given as a trial in suspected asthma. If the child improves after a trial of a steroid inhaler, this helps to confirm the diagnosis.

Question 12

Asthma is associated with low exhaled nitric oxide (FeNO) due to airway inflammation.

Answer 12

False – 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 13

A child >5 on a very low dose inhaled corticosteroid who continues to require their reliever inhaler twice a week should have a long-acting beta agonist added on to their treatment.

Answer 13

True – the BTS/SIGN guidelines would recommend a long-acting beta agonist (LABA) as the next step, and this would be a reasonable next step as per other guidelines.

Question 14

If you are treating a patient who does not speak the same language as you, you should ask them to bring a family member with them to translate.

Answer 14

False – patients have a right to confidentiality. If an interpreter is required, a professional interpreter should be arranged to ensure the patient’s privacy is maintained and no avoidable miscommunication occurs. Of course, if any patient wishes their family member to be present this can be accommodated, but you should still ensure a professional interpreter is present.

Question 15

Spirometry is required to diagnose asthma in adults.

Answer 15

False – as in children, asthma can be diagnosed based on a highly suggestive history, and confirmed by a good response to treatment.

Question 16

In asthma, you would expect a history of consistent symptoms through the day.

Answer 16

False – variability is one of the hallmark features of asthma, and this includes diurnal variation – symptoms tend to be worse at night and in the early morning.

Question 17

You are more likely to have asthma if your mother is asthmatic than if your father is asthmatic.

Answer 17

True – the role of genetics in asthma is complex and not fully understood, but it appears than maternal atopy (cluster of conditions including asthma, allergic rhinitis, hayfever and eczema) has a greater influence on the development of asthma in a child than paternal atopy.

Question 18

Type 2 respiratory failure is a feature of severe COPD.

Answer 18

True – 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 19

On examination, you will often find asymmetrical chest expansion in people with asthma.

Answer 19

False – 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 20

In stable asthma, you would expect to see an FEV1/FVC of <0.7.

Answer 20

False – you will often see normal or near-normal spirometry in asthma, as airflow obstruction is variable. The airway is likely to be obstructed during an acute exacerbation of asthma, but you would not choose this moment to perform spirometry!

Question 21

Treatment-resistant, severe asthma is relatively common in children.

Answer 21

False – Severe airways disease that does not respond to maximal treatment is extremely uncommon in children. More commonly, there are complex psychological and illness behaviour elements to the presentation, which can include not taking the treatment as prescribed. These should be thoroughly explored as part of the patient-centred management.

Question 22

Emphysema is the dilatation of bronchioles leading to air trapping.

Answer 22

False – 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 23

“Tracheal tug” is a sign of respiratory distress in children.

Answer 23

True – tracheal tug, 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 24

Hypoxia increases the blood pressure in the lungs in COPD.

Answer 24

True – 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 25

Cultural competence is the ability to treat all patients the same, regardless of their cultural differences.

Answer 25

False – cultural competence is 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 26

A child under 5 with a new diagnosis of asthma who is symptomatic more than 3 times a week should be started on a leukotriene receptor antagonist.

Answer 26

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

Question 27

Flapping tremor is a sign of hypoxia.

Answer 27

False – flapping tremor is a sign of hypercapnia – carbon dioxide retention.

Question 28

For a diagnosis of chronic bronchitis to be given, a patient should have a cough productive of sputum most days, for 3 consecutive months, for at least 3 years.

Answer 28

False – it only needs to be for 2 years.

Question 29

More than 50% of long-term smokers will develop COPD.

Answer 29

False – surprisingly, less than half of long-term smokers will develop COPD in their lifetime. This demonstrates the interaction between genetic predisposition and environmental factors in the development of COPD

Question 30

On a chest x-ray, hyperinflation is present if you can see more than 6 ribs posteriorly.

Answer 30

False – hyperinflation is present if more than 6 ribs are visible anteriorly, or 10 ribs posteriorly.

Question 31

Humidifiers do not improve asthma control.

Answer 31

True – there is no evidence that dehumidifiers or humidifiers have any effect on asthma control.

Question 32

Most infections causing exacerbations of COPD are viral.

Answer 32

True – although patients will often receive antibiotics for acute infective exacerbations of COPD, in the majority of cases the pathogen is a virus.

Question 33

Respiratory failure in COPD is due to V/Q (Ventilation/Perfusion) mismatch.

Answer 33

False – generally speaking, 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 34

Pulmonary rehabilitation can improve survival from COPD.

Answer 34

True – 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 35

In assessing severity of acute asthma in adults, subjective parameters (eg. distress) are just as important as observations and blood gases.

Answer 35

False – patients and doctors tend to underestimate asthma severity, and a life-threatening attack may not be associated with significant distress. Objective measurements such as vital observations (pulse rate, oxygen saturations, peak flow) and blood gas analysis are most useful.

Question 36

The hallmark of obstructive lung disease is reduced FVC.

Answer 36

False – although the FVC may be reduced, for a lung disease to be considered obstructive there needs to be reduced FEV1:FVC (less than 0.7).

Question 37

The airway obstruction from asthma is reversible.

Answer 37

True – in bronchial asthma, the obstruction is caused by inflammation and smooth muscle contraction, so can reverse spontaneously or with medication.

Question 38

Hypoxia leads to constriction of pulmonary arterioles.

Answer 38

True – in health, this is a protective mechanism. 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 39

Low haemoglobin is a complication of COPD.

Answer 39

False – 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.

Question 40

An excess of alpha-1-antitrypsin can lead to emphysema.

Answer 40

False – 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 41

Patients are eligible for longterm oxygen therapy if they have a PaO2 of <7.3 AND additional complications of chronic hypoxia.

Answer 41

False – 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 42

Pregnancy is a protected characteristic under the Equalities Act (2010).

Answer 42

True – there are nine protected characteristics under the Equalities Act (2010). They are Age, Sexual Equality, Sexual Orientation, Pregnancy and Maternity, Marriage and Civil Partnership, Gender Reassignment, Religion and Belief, Disability and Race

Question 43

Smoking tends to cause emphysema in the bases of the lungs.

Answer 43

False – as emphysema from smoking is caused by inhaled pathogens, it tends to occur in the region of the lung most easily reached by inhaled smoke: the apex. Contrast this to alpha-1-antitrypsin deficiency, where the resulting emphysema tends to affect the base.

Question 44

Spirometry is required to diagnose chronic bronchitis.

Answer 44

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

Question 45

It is important to take a history and perform a full respiratory examination before diagnosing a child with asthma.

Answer 45

False – examination findings are likely to be normal. Diagnosis is from the history!

Question 46

A patient may still have asthma with normal spirometry.

Answer 46

True – remember that variability is a feature of asthma. Normal spirometry cannot rule out intermittent airway obstruction.

Question 47

In chronic bronchitis, new goblet cells appear in small airways.

Answer 47

True – 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 48

“Silent chest” is a reassuring sign that an acute asthma attack is mild.

Answer 48

False – do not be fooled if you listen to someone’s chest during what appears to be a severe acute asthma attack and do not hear wheezing. “Silent chest” means an airway is so obstructed there is hardly any air moving at all. You need an anaesthetist!

Question 49

It is likely that allergies cause the development of childhood asthma.

Answer 49

False – it is likely that an underlying abnormality in the epithelium leads to the development of both asthma and allergies.

Question 50

Centri-acinar emphysema begins with dilatation of the alveoli.

Answer 50

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

Question 51

Carbon monoxide gas transfer in asthma can be normal or increased.

Answer 51

True – gas transfer is calculated by measuring uptake of carbon monoxide, and can be helpful to distinguish between COPD and Asthma. It is reduced in COPD due to alveolar destruction. In asthma it should be normal or slightly increased.

Question 52

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

Answer 52

True – although salbutamol is the most commonly-used reliever medication, terbutaline is also used.

Question 53

In moderate or severe exacerbations of asthma, the pCO2 is normal.

Answer 53

False – this is really important. 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 54

Ipratropium bromide is a long-acting beta agonist.

Answer 54

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

Question 55

COPD is a cause of finger-clubbing.

Answer 55

False – it isn’t! If your patient with COPD has clubbed fingers, look for another cause.

Question 56

In an acute asthma attack, steroids should be given via a nebuliser rather than through a metered-dose inhaler.

Answer 56

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

Question 57

Washing a spacer device before using it increases the static charge and decreases the drug delivery to the lungs.

Answer 57

False – 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 58

Regular use of a brown inhaler in childhood can restrict adult height by up to 3cm.

Answer 58

False – the effect is much less; height restriction is generally about 0.5-1.0cm.

Question 59

Female sex is a risk factor for COPD.

Answer 59

True – 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 60

Omalizumab is a specialist treatment for asthma, and dampens all components of the inflammatory response.

Answer 60

False – omalizumab is 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.