Respiratory Flashcards
(394 cards)
1
Q
What are the 3 indicators of nicotine dependence in smokers?
A
- First cigarette within 30 minutes of waking 2. Smoking more than 10 cigarettes/day 3. Previous withdrawal symptoms on past quit attempts
2
Q
Suppose a patient comes to you for advice about smoking cessation. She has no features of nictoine dependence on history taking. What is the most appropriate management?
A
This patient has low nicotine dependence - there is no evidence that pharmacotherapy is beneficial in these patients. The patient should be offered counselling and behavioural techniques
3
Q
Presume you have a patient with COPD who uses rescue salbutamol but who has had 2 exacerbations of COPD in the past 6 months. What is the next most appropriate medication to prescribe?
A
LAMA (titropium) or LABA (salmeterol) - (or comination with both)
4
Q
What spirometry findings are diagnostic of COPD?
A
FEV1/FVC ratio <70% and FEV1 <80% predicted after bronchodilator
5
Q
Air travel following spontaneous pneumothorax should be delayed for how long?
A
6 weeks
6
Q
When are patients who have had traumatic pneumothorax considered safe to fly?
A
Providing that the lung has fully re-inflated, considered safe at 14 days
7
Q
For patients with asthma that is well controlled, what advice would you give as part of an action plan in regards to worsening asthma control?
A
Increase the dose of preventer during an acute exacerbation as soon as possible, and also increase the frequency of salbutamol/reliever
8
Q
Give at least 3 examples in which you should prescribe an increase in preventer and/or a course of oral steroids for asthma
A
Any of: acute symptoms that recur within 3 hours of taking a reliever; increasing difficulty breathing over 1 or more days; night symptoms that interfere with sleep over more than 1 night in a row; peak flow below a predefined level (for those monitoring peak flow daily, level based on personal history of peak flow before and during flares)
9
Q
What are the ‘red flags’ for hospital admission with CAP?
A
RR 22+, HR greater than 100; SBP <90, acute onset confusion, sats < 92% on room air, multilobar involvement on CXR, lactate more than 2
10
Q
What is the empiric treatment for mild CAP?
A
Monotherapy with Amoxicillin 1g TDS for 5-7 days
11
Q
Why is Amoxicillin the drug of choice for mild CAP monotherapy?
A
Because of the increasing rates of strep pneumoniae resistance to tetracyclines and macrolides
12
Q
Describe the general spirometry pattern in COPD
A
Airflow limitation which is not fully reversible (post bronchodilator FEV1/FVC ratio <0.7 and FEV1 <80% of predicted)
13
Q
How is severity of COPD measured?
A
Determined based upon symptoms and post-bronchodilator FEV1 (% predicted) values
14
Q
What is the definition of mild COPD?
A
Post bronchodilator FEV1 60-80% predicted. Few symptoms, breathless on moderate exertion, little/no effect on daily activities, cough and sputum production
15
Q
What is the definition of moderate COPD?
A
Post bronchodilator FEV1 40-59% predicted. Breathlessness walking on ground level, increasing limitation of daily activities, recurrent chest infections, exacerbations requiring oral steroids and/or antibiotics
16
Q
What is the definition of severe COPD?
A
Post bronchodilator FEV1 <40% predicted. Breathless on minimal exertion, daily activities severely curtailed, exacerbations of increasing frequency and severity
17
Q
What is the most common type of primary lung cancer?
A
Adenocarcinoma (non-small cell), which is the most common type of lung cancer diagnosed in all smokers, ex-smokers and non-smokers
18
Q
Which 4 criteria can be used to diagnose asthma in adults?
A
- History of variable symptoms (SOB, cough, wheeze, chest tightness) 2. Expiratory airflow limitation demonstrated on PFTs (FEV1/FVC less than LLN for age) 3. Expiratory airflow limitation has been shown to be variable 4. No alternative diagnosis is suspected
19
Q
By what age can young people be managed with asthma as per the adult algorithms?
A
Mid-adolescence 14-16 years
20
Q
True or false? Early puberty is an independent risk factor for persistence of asthma into adolescence and the severity of athsma in adulthood
A
True - but the mechanism is unclear (?effects of hormonal changes on reactivity of airways vs risk factors that are common to both asthma and early puberty)
21
Q
True or false? Increased BMI in girls has been associated with both early puberty and increased asthma risk
A
True.
22
Q
Is there a difference between asthma remission rates in adolescence between boys and girls?
A
Yes, boys have higher rates of remission after initially being the gender with higher prevalence in the 0-14 age group
23
Q
What is the recommendation for investigating asthma-like symptoms in adolescents and young adults?
A
Use spirometry to assess lung function objectively, even if the person had asthma during childhood
24
Q
What is the recommendation for investigating exercise-related asthma symptoms in adolescents?
A
Consider objective tests (exercise testing, bronchial provocation) or referral for investigation of possible non-asthma causes like poor CV fitness, hyperventilation or upper airways dysfunction
25
In adults and adolescents, what symptoms constitute 'good control' of asthma?
All of: Daytime symptoms 2 or less times per week; need for reliever 2 or less times per week (not including if taken prophylactically before exercise); no limitation of activities, no night symptoms or on waking
26
In adults and adolescents, what symptoms constitute 'partial control' of asthma?
1-2 of: daytime symptoms >2 days per week; need for reliever >2 days per week; any limitation in activities; any night symptoms or on waking
27
In adults and adolescents, what symptoms constitute 'poor control' of asthma?
3 or more of: daytime symptoms > 2 days per week; Need for reliever >2 days per week; any limitation of activities, any symptoms during night or on waking
28
When assessing asthma control, symptoms are based on those experienced in what recent time frame?
The past 4 weeks
29
Low dose ICS treatment is indicated for adults and adolescents with asthma with what criteria? (Name 3)
Daytime symptoms 2 + times per month, any waking with asthma, any severe flare-up within the past year, or other risk factors for severe flare ups
30
Name at least 4 risk factors for undiagnosed asthma among adolescents
Female, smoking (current and also exposure), low SES, family problems, low phyiscal activity and high body mass
31
For adolescents with exercise-related wheeze and breathlessness, what common conditions should be considered in the diagnosis?
Poor CV fitness, exercise-induced upper airway dysfunction (spectrum of conditions characterised by inducible airway obstruction including vocal cord dysfunction) and exercise-induced hyperventilation
32
What is the relationship between laughter-triggered wheeze in children and asthma?
Presence of resp symptoms that are triggered by laughing in children increases probability of symptoms being due to asthma (but laughter is a common cause of wheeze in infants)
33
What is the relationship between the premenstrual/menstrual phase and asthma in women?
Asthma worsens in the premenstrual phase in up to 40% of women (?due to reduced response to corticosteroids and bronchodilators), perimenstrual worsening of asthma is relatively common among women with poorly controlled or severe asthma
34
How is asthma defined clinically, as per the asthma handbook?
Asthma is defined clinically as the combination of variable respiratory symptoms (e.g. wheeze, SOB, cough and tightness) and excessive variation in lung function (variable airflow limitation)
35
In regards to asthma, what is meant by 'variable airflow limitation'?
Excessive variation in lung function - i.e., variation in expiration airflow that is greater than seen in healthy people
36
What are 'variable symptoms' in asthma?
Respiratory symptoms (cough, tightness, wheeze, SOB) that vary over time and may be present or absent at any point in time
37
Name some of the pathophysiological factors associated with untreated asthma
Chronic inflammation involving many cellular elements, airway hyperresponsiveness, intermittent airway narrowing (due to bronchoconstriction +/- congestion/oedema of bronchial mucosa +/- mucus
38
What is the 'gold standard' test for diagnosing asthma?
This is a trick question - there is no single reliable test and no standard diagnostic criteria - the diagnosis is based on history, examination, consideration of other diagnoses and documentation of variable airflow limitation
39
What spirometry findings are diagnostic for asthma?
1. Reversible airflow limitation (FEV1 increase 200mL or more and 12% or more from baseline). 2. Expiration airflow limitation (FEV1/FVC < LLN for age)
40
Name at least 5 factors which make asthma more likely when investigating respiratory symptoms in a child
More than 1 of wheeze/cough/tightness/SOB; symptoms recurrent or seasonal, worse at night or early morning, hightory of allergies, symptoms clearly triggered by exercise/cold/irritants/allergens/viral infections/laughter; family history of atopy, widespread wheeze on auscultation, symptoms rapidly relieved by SABA, symptoms occurring when child doesn't have a cold
41
Name at least 5 factors which make asthma less likely when investigating respiratory symptoms
Dizziness, light headedness, peripheral tingling, isolated cough with no other respiratory symptoms, chronic sputum production, moist cough, normal exam when symptomatic, changes in voice, symptoms only present with URTI, normal PFTs when symptomatic
42
Aside from asthma, list the other possible differential diagnoses for widespread wheeze on auscultation
COPD, viral/bacterial respiratory infection, tracheomalacia, inhaled foreign body, sometimes obesity alone
43
Bronchodilator reversibility is performed on spirometry before and after administration of what dose of SABA?
4 puffs salbutamol 100mcg/actuation via pressurised MDI (then repeat testing 10-15 mins after)
44
What is FEV1?
Forced expiratory volume over a specified time frame (1 = 1 second)
45
What is the recommended management for an adult patient with suspected asthma, who shows some improvement in FEV1 after SABA but does not meet criteria for reversible airflow limitation?
Consider other investigations +/- trial of 4-6 weeks of regular low-dose ICS plus SABA PRN, with repeat spirometry following to see whether there is a significant improvement in symptoms and lung function
46
Whilst peak expiratory flow meters/flow rate should not be used as a substitute for spirometry in asthma, it can support the diagnosis in some patients. What diagnostic parameters on peak flow are supportive of asthma?
Greater than 10% diurnal variation in peak expiratory flow rate with BD readings (averaged over 1 week) is suggestive
47
What is peak flow measuring?
Gives an idea of how narrow or obstructed the airway is by measuring the maximum (peak) rate at which they can blow air into a peak flow meter after a deep breath.
48
What is the definition of a 'clinically important increase or decrease in lung function' In the assessment of asthma?
Change in FEV1 of at least 200mL and 12% from baseline for adults (or at least 12% change from baseline for children) or a change in peak expiratory flow rate of at least 200% on the same meter
49
Variable airflow limitation can be documented for patients if any of which criteria are met?
1. Clinically important increase in FEV1 after bronchodilator 2. Clinically important variation in lung function (20% change in FEV1) measured repeatedly over time 3. Clinically important reduction in lung function after exercise 4. Clinically important increase in lung function after a trial of 4 weeks with ICS 5. Clinically important variation in peak expiratory flow (diurnal variability greater than 10%) 6. Clinically important reduction in lung function during a test for airway hyper responsiveness (i.e., exercise challenge test or bronchial provocation)
50
When investigating asthma in smokers and ex-smokers over 35 and in people over 65 years old, if expiratory airflow limitation is not completely reversible, what diagnoses should be considered?
COPD, or asthma-COPD overlap
51
What is the definition of upper airway dysfunction, as per the Aus asthma handbook?
Intermittent, abnormal adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. It commonly mimicks and is misdiagnosed as asthma (can cause severe acute episodes of dyspnoea that occur unpredictably or due to exercise)
52
What is the considered to be the best method to confirm the diagnosis of upper airway dysfunction?
Direct visualisation of the vocal cords
53
Long acting B2 agonists (LABA) and long acting muscarinic antagonists (LAMA) should not be used by people with asthma-COPD overlap unless they are also taking which other medication?
ICS (either in combination or separately)
54
In patients with asthma-COPD overlap, which medication forms an essential part of treatment and why?
Inhaled corticosteroid at low-moderate dose - to reduce the risk of potentially life-threatening flare ups, even if asthma symptoms appear mild or infrequent
55
Most patients with asthma-COPD overlap will require treatment with an ICS plus which other medication?
A long acting bronchodilator (either a long acting B2 agonist or a long acting muscarinic antagonist)
56
ICS treatment is associated with an increased risk of which other respiratory condition in people with COPD?
Non-fatal pneumonia
57
Which patient groups are most likely to present with asthma-COPD overlap?
People with current asthma who have had significant exposure to smoking, people with long standing or late asthma who have become persistently SOB over time, people with significant smoking history and symptoms consistent with COPD who also have a history of childhood asthma, people who present in middle/late age with SOB who have a childhood asthma history but few symptoms in between and little smoking history
58
Give 1 example of an ICS-LABA combination for treatment of asthma-COPD overlap that is taken once daily
Fluticasone furoate + vilanterol (Breo Ellipta 100/25)
59
Give 1 example of an ICS-LABA combination for treatment of asthma-COPD overlap that is taken twice daily
Budesonide + formoterol (symbicort rapihaler or symbicort turbhaler)
60
Give 1 example of a LABA for treatment of asthma-COPD overlap (ensure patient also using an ICS)
Salmeterol (BD dosing), aka Serevent accuhaler
61
Give 1 example of a LAMA for treatment of asthma-COPD overlap (ensure patient also using an ICS)
Tiotropium (once daily), aka Spiriva or Spiriva Respimat. Another common example is Umeclidinium (Incruse Ellipta) which is also once daily, or Aclidinium (Genuair) which is twice daily
62
Give 1 example of a LAMA/LABA for the treatment of asthma-COPD overlap that is taken once daily (ensure patient also taking an ICS)
Olodaterol + tiotropium (Spiolto Respimat)
63
How can you confirm that airflow limitation is variable in an adult?
Based on showing variability in FEV1 on spirometry - Spirometry before and 10-15 minutes after a SABA, spirometry on separate visits, spirometry before and after exercise, spirometry before and after trial of ICS treatment, peak flow measured BD, in airway hyper responsiveness testing
64
A clinical diagnosis of asthma is based on which factors?
Based on the probability that symptoms are due to asthma rather than another cause, and on the magnitude of deviation from the level of lung function and variation in lung function that is seen in a healthy population (i.e., demonstrating variable airflow limitation)
65
After making a diagnosis of asthma in adults, what treatment should be commenced?
4-6 weeks of either a short acting beta 2 agonist PRN, or regular ICS (plus SABA PRN)
66
List at least 5 conditions which can be confused with asthma in adults, and which are characterised by cough
Pertussis, GORD, rhinosinusitis, medications (ACE-1), bronchictasis, COPD, pulmonary fibrosis, large airway stenosis, habit-cough syndrome, inhaled foreign body
67
List at least 2 conditions which can be confused with asthma in adults, and which are characterised by wheezing
Respiratory infections, COPD, upper airway dysfunction
68
List at least 5 conditions which can be confused with asthma in adults, and which are characterised by difficulty breathing
Breathlessness due to poor CV fitness, hyperventilation, anxiety, chronic heart failure, pulmonary hypertension, lung cancer
69
Assume a patient comes to see you with a history of asthma and already taking an ICS. On history, they report few respiratory symptoms, and spirometry does not demonstrate variable airflow limitation. What is the next recommended step in management?
If there is no clear history of prior variable airflow limitation, consider back titrating the preventer by 1 step. For ICS, reduce dose by 50%, and review spirometry 2-3 weeks later. If there is still no evidence of airflow limitation, consider stopping ICS and repeating spirometry again 2-3 weeks later.
70
The possibility of work-related asthma should be considered if any of which 3 factors are present?
Timing of symptoms associated with work (especially if improve when away from work), exposure to substances known to cause occupational asthma, coworkers with respiratory symptoms
71
List at least 3 occupations commonly associated with asthma triggers
Bakers, vehicle spray painters, healthcare workers, lab animal workers, agricultural workers
72
Which special diagnostic tests can be used in adults to help identify emphysema or pulmonary fibrosis?
Lung volumes and diffusing capacity
73
Which special diagnostic test can be used in adults presenting with asthma symptoms, where bronchiectasis is suspected?
High res CT
74
In patients with asthma and chronic cough, name at least 7 findings which suggest a serious alternative or comorbid diagnoses that require further investigation?
Haemoptysis, smoker with > 20 pack year history, smoker aged 45+ years with new cough/voice change/changed cough, prominent dyspnoea esp at night, substantial sputum production, hoarseness, fever, weight loss, complicated reflux, swallowing disorders, recurrent pneumonia
75
What are the main roles of bronchial provocation tests of airway hyperresponsiveness?
To exclude asthma as a cause of recurrent symptoms, and to confirm the presence of exercise-induced bronchoconstriction
76
Name the types of bronchial provocation tests for airway hyperresponsiveness
Direct challenge tests (e.g., methacholine challenge test), indirect challenge tests (exercise challenge test, eucapnic volunatry hyperpnea, hypertonic saline, mannitol challenge test)
77
What is the role of sputum eosinophillia testing in asthma diagnosis?
Patients with untreated asthma have airway inflammation (eosinophilic+/- neutrophilic) but testing is not essential for making the diagnosis if the patient shows clinical features of asthma and a low probability that it is due to another cause (and some asthma is not associated with eosinophilia)
78
What is the role of peripheral blood eosinophil count in people with asthma?
In severe asthma, higher count is associated with greater risk of poor symptom control, and is important for predicting response to monoclonal antibody therapy (requirement for eligibility for some treatments)
79
Presume you suspect allergic triggers in a patient with asthma. What is the next step in investigation?
Referral to a specialist allergist/appropriate provider for skin prick testing to common aeroallergens (need to minimise risk - this is the first line as per ASCIA)
80
If skin prick testing is unavailable, and you wish to investigate suspected allergic triggers in a patient with asthma, what could be done?
Blood test (immunoassay for allergen specific IgE)
81
List 3 medications which interfere with allergy skin prick testing
Antihistamines that cannot be withdrawn, TCAs or Pizotifen
82
List at least 3 contraindications to allergy skin prick testing
Severe dermatographism, extensive skin rash, risk of anaphylaxis including occupational asthma due to latex sensitivity
83
You have just made a diagnosis of asthma in an adult. They have symptoms less than twice per month, and never wake due to symptoms, and have no history of a flare up requiring steroids in the past 12 months. List an appropriate starting treatment regimen for this patient.
SABA as needed (Ventolin 100mcg, up to 12 puffs PRN with spacer)
84
You have just made a diagnosis of asthma in an adult. They have symptoms 3 times per month and sometimes wake up due to symptoms. List an appropriate starting treatment regimen for this patient.
Regular low dose ICS + PRN SABA (or as needed low dose budesonide-formoterol, i.e., Symbicort)
85
You have just made a diagnosis of asthma in an adult. They are having frequent daily symptoms on most days of the week. What is an appropriate starting treatment for this patient?
Medium to high dose ICS plus PRN SABA (with plan to down titrate ICS when symptoms improve). Or regular daily maintenance low dose ICS-LABA + PRN SABA (private script).
86
You have just made a diagnosis of asthma in an adult. They are having severely uncontrolled symptoms, including waking every night. What is an appropriate starting treatment for this patient?
High dose ICS + PRN SABA OR daily ICS-LABA + PRN SABA. Could also consider short course of oral steroid in addition to an ICS based treatment
87
Before spirometry, comment on the appropriate withholding times for SABA/SAMA, LABA, LAMAs
SABA/SAMA 4 hours. BD LABAs for 12 hours and once daily LABA for 2 hours. LAMA for 24 hours
88
A diagnosis of asthma in children should not be made if cough is the only symptom and there are no signs of airflow limitation, such as _____ or ______
Wheeze, breathlessness
89
List at least 4 physical examination signs of allergic rhinitis
Swollen turbinates, transverse nasal crease, mouth breathing, darkness and swelling under the eyes caused by sinus congestion, polyps
90
It is a red flag for children aged 1-5 to present with signs/symptoms of asthma which had an onset very early in life, or from birth. What alternate diagnoses should be considered in these children?
CF, chronic lung disease of prematurity, primary ciliary dyskinesia, bronchopulmonary dysplasia, congenital abnormality
91
In a child with crepitations on chest exam that do not clear with coughing, what serious illnesses need to be considered?
Lower respiratory tract conditions such as pneumonia, atelectasis and bronchiectasis
92
What respiratory conditions in children can cause finger clubbing?
CF and bronchiectasis
93
List 4 differentials for chronic wet cough lasting >4 weeks in a child aged 1-5
CF, bronchiectasis, chronic bronchitis, recurrent aspiration, immune abnormaltiy, ciliary dyskinesia
94
What important serious condition should be considered in a child under 5 years old, presenting with asthma symptoms and nasal polyps?
CF
95
What is the cause of wheeze and what does it's presence suggest?
Turbulent airflow due to narrowing of intrathoracic airways, and indicates airflow limitation, irrespective of the underlying mechanism (i.e., bronchoconstriction or secretions)
96
What is the most common symptom associated with asthma in children ages 5 and under?
Wheeze
97
What is the most common cause of wheezing in an infant less than 12 months of age?
Acute viral bronchiolitis or small/floppy airways
98
What is atopic asthma?
Asthma characterised by eosinophilic airway inflammation associated with sensitisation to aeroallergens (positive skin prick test or specific IgE on serology)
99
What is the most common type of asthma in children?
Atopic asthma
100
List at least 3 congenital conditions which are differentials for asthma in children aged 1-5
Structural airway problems (tracheomalacia, bronchopulmonary dysplasia, malformation causing narrowing of intra thoracic airways, vascular ring compressing bronchus, trachea-oesophageal fistula), CF, immune deficiency, primary ciliary dyskinesia, congenital heart disease
101
List at least 3 infective conditions which are differentials for asthma in children aged 1-5
Bronchiolitis (ages <12 months), croup, chronic rhinosinusitis, recurrent resp tract infections, chronic suppurative lung disease
102
List at least 3 acquired conditions which are differentials for asthma in children aged 1-5
Inhaled foreign body, GORD, recurrent aspiration, tumour or pulmonary oedema
103
List at least 4 red flags for cough in children
Wet cough > 4 weeks, obvious difficulty breathing at rest or at night, systemic symptoms including failure to thrive, choking or vomiting, recurrent pneumonia, inspiratory stridor (other than in croup), abnormal resp exam, abnormal CXR findings, clubbing
104
In children with no abnormalities detected on examination, CXR or spirometry, and no other asthma symptoms of airflow limitation, chronic cough is most likely to be due to which 3 causes?
Protracted bacterial bronchitis (resolves with 2-6 weeks antibiotics), post-viral (resolves with time), due to exposure to smoking or other pollutants
105
True or false? Most cases of coughing in preschool children aged 1-5 are not due to asthma
True. Most likely due to recurrent viral bronchitis
106
For what indications should a CXR be ordered for a child aged 1-5 presenting with wheeze and a differential diagnosis of asthma?
If unusual respiratory symptoms or if wheezing is localised
107
Describe an appropriate treatment trial for preschool wheeze in a child older than 12 months
For episodes of wheeze associated with increased WOB, including if occurs in consult, given 2-4 puffs ventolin and observe response. If the increased WOB responds, consider whether a preventer is indicated (table in handbook with frequency of symptoms - i.e., always for kids who have had flares requiring ED/oral steroids etc, and consider in the community for symptoms every 4-6 weeks or less)
108
In infants under 12 months old, what is the most likely cause of respiratory distress?
Bronchiolitis
109
Bronchodilators are not recommended for children under what age?
12 months
110
What care is recommended for a new plastic spacer prior to use?
Removal of electrostatic charge by washing in dishwashing liquid and allowing to air/drip dry without wiping or rinsing. Or, prime by actuating the device several times (though this wastes medicine)
111
In spirometry, reduced _____ alone does not indicate that a child has asthma, becuase it may be seen with other lung diseases or be due to poor technique. However, reduced ____ for age indicates expiratory airflow limitation
FEV1; FEV1/FVC ratio
112
A provisional diagnosis of asthma can be made in children 6 years and older if they have all of which 4 features?
1. Wheezing accompanied by breathing difficulty or cough 2. Other features that increase the probability of asthma such as history of allergic rhinitis, atopic dermatitis or a strong family history of asthma or allergies 3. no signs that suggest a serious alternative diagnosis 4. clinically important response to bronchodilator demonstrated on spirometry
113
In the workup of asthma in a child older than 6, if asthma is suspected but spirometry does not demonstrate a clinically important response to bronchodilator, what can be done?
Repeat spirometry when the child has symptoms
114
List and describe the 3 categories of frequency of asthma flareups in children
Infrequent intermittent (6 weekly symptoms and none in between); frequent intermittent (more than once every 6 weeks with no symptoms between); persistent (any of: daytime symptoms more than once/week, night symptoms more than twice/month or symptoms that restrict activity or sleep)
115
List at least 2 examples of low dose ICS in children
Beclometasone diproprionate 100-200mcg (QVAR); budesonide 200-400mcg (Pulmicort); fluticasone proprionate 100-200mcg (Flixotide)
116
List at least 3 examples of high dose ICS in children
Beclometasone diproprionate >200mcg (max 400); budesonide >400mcg (max 800); fluticasone proprionate >200mcg (max 500)
117
What is the difference between indications for ICS in children 6 years and over with asthma vs children ages 1-5 with preschool wheeze?
In the 1-5 age group, depends on the frequency of symptoms/wheeze (once weekly up to 6 monthly or less) as well as severity. In the over 6's it is based on frequency of flare ups and symptoms in between (i.e., infrequent intermittent, frequent intermittent, persistent) as well as the severity
118
List the 5 asthma patterns in children 6 years and older who are not taking a regular preventer
Infrequent intermittent, frequent intermittent, persistent asthma (mild), persistent asthma (moderate), persistent asthma (severe)
119
What is the definition of infrequent intermittent asthma in a child 6 years or older?
Symptom-free for at least 6 weeks at a time (flare ups up to once every 6 weeks but no symptoms in between)
120
What is the definition of frequent intermittent asthma in a child 6 years or older?
Flare ups more than once every 6 weeks on average but no symptoms between flare ups
121
What is the definition of mild persistent asthma in a child 6 years or older?
FEV1 greater than or equal to 80% predicted and at least 1 of: daytime symptoms more than once/week but not every day; night-time symptoms more than twice/month but not every week
122
What is the definition of moderate persistent asthma in a child 6 years or older?
Any of: FEV1 <80% predicted, daytime symptoms daily, night time symptoms more than once/week, symptoms sometimes restricting activities/sleep
123
What is the definition of severe persistent asthma in a child 6 years or older?
Any of: FEV1 less than or equal to 60% predicted, continual daytime symptoms, frequent night time symptoms, frequent flare ups, symptoms frequently restrict actitivy or sleep
124
Children aged 6 or over who wheeze only during upper respiratory tract infections can be considered to have what diagnosis?
Episodic viral wheeze
125
Dispensing _____ (number) ventolin canisters in a year is associated with an increased risk of asthma flareups in children, while ____(number) or more is associated with an increased risk of asthma death
3; 12
126
What is the main reason why ICS have maximum dose cut offs in children?
Because above a certain threshold, the risk of adrenal suppression increases exponentially
127
What sort of drug is montelukast?
Leukotrine receptor antagonist preventer
128
What are the adverse effects of montelukast?
Behavioural and/or neuropsychiatric, including suicidality
129
What advice should be given to patients with asthma in regards to ICS treatment during the covid pandemic?
Continue taking as prescribed, warn that stopping increases risk of severe asthma flare ups, including those triggered by viral infections, ensure asthma action plan up to date and they have access to all medications prescribed (avoid panic buying and hoarding), advise not to share puffers, encourage covid 19 vaccination
130
True or false? ICS treatment is indicated for all adults, adolescents and children with asthma to reduce the risk of flares
False. ICS treatment is indicated in most adults and adolescents, whereas indications in chlidren depend on the age group and the pattern of symptoms and flare ups
131
True or false? Monoclonal antibody (biologic) therapy for asthma (i.e., the 'mabs') are immunosuppresants
False.
132
For patients with asthma taking biologic therapy, what is the advice regarding covid 19 vaccination?
Safe and should be immunised. If possible, the biologic shouldn't be administered on the same day as the vaccine so that, should adverse effects occur, the cause will be easier to identify (ASCIA recommend not within 48 hours)
133
COVID-19 is caused by a coronavirus from which family?
Betacoronavirus
134
Describe the pathophysiology of covid 19 infection
Infection occurs when a spike glycoprotein on the virus surface attaches to the ACE-2 receptor on human epithelial cells in the mouth, nose and airways.
135
What is the average incubation period of covid?
6 days
136
At which days of covid 19 infection do symptoms typically worsen?
Days 4-9
137
For how many days can covid aerosol particles survive on steel and plastic surfaces?
3 days
138
What is the relationship between asthma and death from covid 19?
Overall, people with asthma are not an increased risk of infection or covid-related death, however use of oral corticosteroids used in the preceding year is associated with increased risk of death (presumably suggesting the severe or uncontrolled asthma is associated with higher risk)
139
For adults and adolescents with asthma that has been well controlled for ___ months, consider stepping down therapy
2-3
140
State 2 options that are considered to be suitable starting treatments for most new adult patients with asthma
Regular low dose ICS (e.g. Flixotide/fluticasone proprionate 100-200mcg/day) + PRN SABA (Salbutamol) or low dose budesonide-formoterol (Symbicort) PRN
141
Which adult patients with new onset asthma as suitable to receive only PRN SABA as first line management?
Symptoms less than twice/month and no risk factors for flare ups (history of poor control, flare up in last 12 months, other lung disease, poor lung function, eosinophilic airway inflammation, exposure to cigarette smoke, low SES, mental illness)
142
Give at least 3 example of low dose ICS in adults
Beclometasone diproprionate 100-200mcg (QVAR), budesonide 200-400mcg (Pulmicort), fluticasone proprionate 100-200mcg (Flixotide)
143
List the 2 types of SABA available in Australia
Salbutamol (Ventolin/Asmol) and Tubutaline (Bricanyl). This category also includes low dose budesonide-formoterol (symbicort) PRN or as maintenance and reliever treatment)
144
For an adult patient with new asthma with frequent or uncontrolled symptoms, name an appropriate initial treatment option (this is also the step up treatment option for adults with poorly controlled symptoms on basic initial treatment)
Regular daily low dose ICS-LABA (I.e., Seretide -Fluticasone Proprionate/salmeterol or Symbicort (budesonide/formoterol) which can be used as maintenance-and-reliever therapy with regular daily maintenance plus low dose as needed. OR Regular Daily Low dose mainenance ICS-LABA combination plus SABA as needed
145
For patients with asthma not responding to regular daily low dose ICS-LABA, what is the step up treatment option?
Increase to medium-high dose of daily ICS-LABA (i.e., Symbicort as regular daily maintenance plus lose dose PRN). Or regular daily ICS-LABA at higher Doses + SABA as needed. Consider referral and add on treatments such as tiotropium
146
When assessing asthma control in adults, what 4 criteria are indicative of good recent asthma symptom control?
Must have all 4 of: daytime symptoms 2 or less days/week, need for SABA 2 or less days/week, no limitation of activities and no symptoms at night or on waking
147
When assessing asthma control in adults, which 4 criteria are considered to be indicative of partial or poor recent symptom control?
1 or 2 of the following is considered partial control, 3 or more considered poor control: daytime symptoms >2 days/week, needs for SABA >2 times/week, any limitation of activities, any symptoms at night or on waking
148
For adult patients who are using SABA only for asthma symptoms, even if they meet the criteria for good control, in what situations would an ICS be indicated?
Daytime symptoms 2 or more times/month, any waking with asthma, any severe flare up within the past year, risk factors for severe flare ups
149
What definition is used to identify asthma patients with high SABA use?
>3 cannisters/year. These patients should have lung function checked
150
List at least 5 risk factors associated with increased risk of life-threatening asthma
Intubation or admission to ICU ever, 2+ hospitalisations in past year; 3+ ED visits in the past year; hospitalisation/ED in past month, high SABA use, more then 3 cannisters/year, history of delayed presentation during flare ups, CVD, history of sudden onset acute asthma, sensitivity to unavoidable allergen, lack of action plan, SES disadvantage, living alone, mental illness, illicit substance use
151
What are the 2 main factors associated with thunderstorm asthma?
Springtime allergic rhinitis, ryegrass pollen allergy
152
Give at least 2 examples of questionnaire-based tools that can be used to standardise review of asthma symptoms in Australian patients
PACS - primary care asthma control screening tool. Asthma control questionnaire (ACQ)
153
Give at least 3 examples of when spirometry can be helfpul in ongoing asthma management in adults
During a flare up to provide objective evidence of severity of bronchoconstriction, after a dose adjustment to measure response to treatment, to identify whether symptoms are due to non-asthma conditions (i.e., if FEV1 above 80-90% should prompt further Ix), identify patients who are poor perceivers of airflow limitation, rate of change of lung function decline
154
List 3 pieces of advice that should be given to patients using PRN low dose budesonide-formoterol (Symbicort) as a reliever without a regular daily maintenance preventer
Use inhaler as needed for symptoms; take extra doses if symptoms increase; the Symbicort replaces any previous short acting reliever they had before; if they also get exercise-induced symptoms, consider using before exercise
155
List the 3 uses of SABAs
Relieve asthma symptoms; prevent exercise-induced bronchoconstriction; relieve exercise-induced bronchoconstriction
156
What is the duration of therapeutic effect of a SABA?
4 hours
157
Explain why high use of SABAs may increase the risk of asthma flare ups
Regular use results in receptor tolerance (down regulation) to their bronchoprotective effects. This tolerance becomes more apparent with worsening bronchoconstriction which could lead to a poor response to emergency treatment
158
What is the appropriate treatment setting for a patient with asthma who is requiring SABA at intervals less than 4 hours?
Needs medical supervision and ideally also receiving systemic corticosteroids
159
In adults, how should use of an MDI inhaler + spacer be used?
In adults, shake the inhaler, breathe out all the way into the spacer, actuate a single puff into the spacer and then immediately take a slow deep breath from the spacer and then hold breath for 5 seconds. Tidal breathing through the spacer is used in acute asthma and for young children
160
List the only 2 budesonide/formoterol inhalers that can be used as PRN regimens without concomittant maintenance treatment
Budesonide 200/formoterol 6mcg via dry powder inhaler (1 puff - Symbicort Turbihaler) and budesonide 100/formoterol 3mcg via MDI (2 puffs - Sympbicort rapihaler)
161
LABAs for asthma should only be used when which other medicationis taken concurrently? (i.e., they are not appropriate for monotherapy alone)
Inhaled corticosteroids
162
For adults with asthma who have very well controlled symptoms and who would prefer not to take a long term ICS, what is a suitable alternative?
PRN low dose budesonide-formoterol (Symbicort)
163
List at least 4 known benefits of ICS in patients with asthma
Reduces symptoms, improves QOL, improves lung function, decreases airway hyperresponsiveness, controls airway inflammation, reduces frequency and severity of asthma flare ups, reduces risk of death due to asthma
164
Most of the benefit of ICS is achieved with doses at the upper limit of the low dose range. State these dose ranges for 2 common ICS
Budesonide 400mcg (Pulmicort), fluticasone proprionate (Flixotide) 200mcg
165
List at least 2 local and systemic adverse effects which can occur with higher doses of ICS
Local - hoarseness, candidiasis. Systemic - HPA axis changes, i.e., adrenal suppression
166
The risk of adrenal suppression from high dose ICS is more common when patients are also taking which medications?
Those that inhibit cytochrome P450 (erythromycin, ketoconozole)
167
Montelukast is less effective than ICS for controlling asthma symptoms in adults, but it may be considered as an alternative in which 2 main situations?
People who experience intolerable dysphonia with ICS despite correct technique, and people who refuse other preventer options (it can also have some favourable effects in patients with aspirin exacerbated respiratory disease)
168
True or false? In adults with asthma that is not controlled by a low dose ICS, montelukast is the next most effective add on treatment
False. Montelukast is less effective than the addition of a LABA, and it is also associated with lesser improvement in lung function and QOL
169
Give at least 2 appropriate standard initial maintenance doses of budesonide-formoterol (Symbicort) used in a maintenance-and-reliever regimen
Budesonide 200/formoterol 6mcg dry powder inhaler (1-2 inhalations BD, Symbicort Turbuhaler); budesonide 100/ formoterol 3mcg MDI (2-4 puffs BD - Symbicort Rapihaler)
170
True or false? In adults whose asthma is not well controlled by taking low-dose ICS, switching to a combination ICS-LABA is more effective than increasing to a higher dose of ICS alone
True.
171
What is the relationship to clinical outcome when starting preventer ICS-LABA in combination rather than with an ICS alone for patients with asthma?
The ICS-LABA is not more effective at reducing flare ups, but it does improve lung function, reduces symptoms and marginally reduces the requirement for SABA. It is not more effective in reducing the risk of flare ups that require treatment with an oral steroid compared with starting with a higher dose of ICS initially
172
What dose adjustment should be expected when switching an asthma patient from an ICS to budesonide/formoterol combination as maintenance and reliever therapy?
It is expected that the maintenance dose of the ICS will be reduced
173
What should be considered in step-down therapy of asthma management in pregnant women?
Only consider stepping down if the woman is taking an inappropriately high dose of a medicine - step down is not a priority in pregnancy due to the risk of flare up
174
When stepping down adult asthma management, make small adjustments by reducing ICS dose by ____ at intervals of ____ by stepping down through the available doses
25-50% every 2-3 months
175
For adolescents taking low dose ICS and symptoms have been well controlled for several months, consider switching to what therapy?
PRN low dose ICS-LABA or trial of cessation of ICS with planned follow up (do not offer cessation if there are any risk factors for severe flare ups)
176
In regards to an asthma action plan for adults: for patients using a SABA only, what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Start regular ICS preventer and continue for at least 2-4 weeks
177
In regards to an asthma action plan for adults: for patients using PRN low dose budesonide-formoterol only, what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Increase use as needed
178
In regards to an asthma action plan for adults: for patients using an ICS preventer only, what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Increase dose early (i.e., multiply dose by 4 for 7-14 days)
179
In regards to an asthma action plan for adults: for patients using an ICS-LABA combination (budesonide-formoterol) on a maintenance-and-reliever regimen, what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Take extra doses of Symbicort as needed to relieve symptoms (no more than 6 actuations at once and max 12 daily of dry powder, or 24 of the MDIs)
180
In regards to an asthma action plan for adults: for patients using an ICS-LABA (budesonide-formoterol) on a maintenance only regimen + PRN SABA, what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Increase dose of maintenance Symbicort for 7-14 days
181
In regards to an asthma action plan for adults: for patients using an ICS-LABA combination with fluticasone proprionate-salmeterol (Seretide), what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Increase ICS dose (multiply by 4) by adding a separate fluticasone proprionate inhaler for 7-14 days.
182
List 5 pieces of advice that should be given to asthma patients who need long term high dose ICS to maintain good control
Check for oral thrush. Monitor BP and BGL. Should have BMD at baseline and repeated every 1-5 years. Have regular eye exams to check for cataracts and glaucoma, do regular weight bearing activity, have adequate dietary calcium intake and maintain adequate Vit D levels, consider screening for adrenal suppression
183
In Australia, for which group of asthma patients may peak flow monitoring play a role in management?
Patients with severe asthma, history of frequent flare ups or poor perception of airflow limitation. Should be done BD and recorded.
184
True or false? Patients with asthma should be advised not to take their preventer puffer before spirometry
False. But it should be documented whether they have taken a combination preventer that contains a LABA on the day. When spirometry is performed as a diagnostic test, inhaled bronchodilators should be withheld, but SABA should still be used for relief of symptoms. When spirometry is performed for monitoring, bronchodilators should not be witheld
185
What does it mean to say that a patient with asthma as poor perception of airflow limitation?
Those who do not feel any different with a 15% increase or decrease in FEV1
186
What is the clinical definition of a mild asthma flare up, and give an example of this?
Worsening of asthma control that is only just outside the normal range of variation for the individual. E.g., needing reliever more than usual, waking up with asthma, symptoms interfering with usual activities (a gradual reduction in PEF over several days)
187
What is the clinical definition of a moderate asthma flare up, and give an example of this?
Events that are all of: troublesome/distressing, require a change in treatment, not life threatening and do not require hospitalisation. E.g., more symptoms than usual, increasing difficulty breathing, waking often at night with symptoms
188
What is the clinical definition of a severe asthma flare up, and give an example of this?
Events that require urgent action by the patient or carers and health professionals to prevent a serious outcome such as hospitalisation or death. E.g., needing reliever again within 3 hours, difficulty with normal activity
189
For adults with asthma, list the 4 situations where an increase in preventer and/or a course of oral steroids should be prescribed
For patients with any of: acute asthma symptoms that recur within 3 hours of taking SABA; increasing difficulty breathing over one or more days; night time asthma symptoms that interfere with sleep over more than 1 night in a row; peak flow below what is normal for the patient (pre agreed based on clinical history)
190
List an appropriate treatment regime of oral corticosteroids for adults who require additional treatment for asthma
Oral prednisolone 37.5mg - 50mg for 5-10 days (not necessary to taper if course is less than 14 days)
191
True or false? Pregnancy is a contraindication for oral steroids in asthma exacerbations
False. Oral prednisolone is rated category A for pregnancy
192
In patients taking maintenance combination fluticasone proprionate/salmeterol (Seretide), ensure that the total daily dose is ______ during a flare up
Total daily dose of salmeterol 100mcg/day (e.g., if patient taking Seretide 250/25 1 puff BD, increase this to 2 puffs BD, or prescribe an additional fluticasone proprionate inhaler for 1-2 weeks to keep the salmeterol dose the same)
193
What should be documented in the asthma action plan for an adult patient who is taking budesonide-formoterol as maintenance-and-reliever treatment with a dry powder inhaler, and suffers from a flare up of symptoms?
Take 1 extra puff when needing relief from symptoms. If needing more than 6 reliever inhalations per day for more than 2-3 days, take action by seeing GP or starting oral steroid course. Present to ED/GP if needing more than 12 puffs in 1 day (but keep taking whilst waiting)
194
What should be documented in the asthma action plan for an adult patient who is taking budesonide-formoterol as maintenance-and-reliever treatment with an MDI, and suffers from a flare up of symptoms?
Take 2 extra puffs when needing relief from symptoms. If needing more than 12 puffs/day for 2-3 days, take action by contacting GP or starting course of oral steroids. Present to ED/GP if needing more than 24 puffs in 24 hours (keep taking whilst waiting)
195
What should be documented in the asthma action plan for an adult patient who is taking PRN low dose budesonide-formoterol only with a dry powder inhaler, and suffers from a flare up of symptoms?
Take more doses if symptoms worsen or do not improve, contact GP/start oral steroids if needing more than 6 puffs per day for 2-3 days, and present to ED/GP if needing more than 12 puffs/day
196
What should be documented in the asthma action plan for an adult patient who is taking PRN low dose budesonide-formoterol only with an MDI, and suffers from a flare up of symptoms?
Take more doses if symptoms worsen or do not improve, contact GP/start oral steroids if needing more than 12 puffs/day for 2-3 days. Go to ED/GP if needing more than 24 inhalations/day
197
When should patients reduce their preventer dose back to normal after an exacerbation?
After 2 weeks
198
What is the definition of severe asthma in adults?
Asthma that remains uncontrolled despite regular treatment with high dose ICS + LABA or with maintenance oral steroids, or asthma that requires this level of treatment (Step 4) to prevent it becoming uncontrolled
199
For adults with severe asthma, give at least 3 examples of ways to optimise their treatment regimen
Consider trial of add on tiotropium (LAMA), consider trial of high dose ICS for 3-6 months, consider trial of add-on montelukast (though evidence is poor). For patients on ICS-LABA and using PRN SABA as a reliever, consider changing to a low dose ICS-LABA for single maintence and reliever therapy to reduce the risk of flare ups
200
Give at least 4 indications to refer a patient with severe asthma to a Specialist
Prolonged high dose ICS required for control, needing maintenance with oral steroid or frequent courses, use of SABA 6-8 puffs/day for several weeks despite appropriate maintenance treatment, frequent or sudden flare ups, if food allergy is suspected
201
Asthma in adults is considered to be uncontrolled if any of which symptoms are present?
Poor symptom control (during night/waking, limitation of activities, daytime symptoms 2+ days/week, need for SABA 2+ days/week), frequent severe flare ups (more than 1 flare requiring oral steroid in the past year), serious flare up (hospital admission in the past year), persistent airflow limitation detected on spirometry
202
True or false? Severe asthma most commonly first presents as milder asthma which eventually progresses
False. Severe asthma seems to be a distinct disease with different pathology, and it is rare for mild asthma to progress to severe asthma
203
People with asthma tend to have more symptoms of reflux. Give one postulated explanation for this.
Via changes in intrathoracic pressure, or from the effects of asthma medications on the gastrooesophageal sphincter. GORD may contribute to bronchoconstriction through vagally mediated reflexes, airwy hyperresponsiveness, chornic microaspiration of gastric fluid etc.
204
List at least 5 common agents associated with irritant-induced occupational asthma
Bleaches, cleaning agents, sealants, diesel exhaust, sulphur dioxide, ammonia, chlorine, chlorofluorocarbons
205
List at least 5 disorders which are independent risk factors for worse asthma control/increased flare ups
Obesity, allergic rhinitis, OSA, reflux, anxiety disorder
206
Foods are rarely a trigger for asthma. Name 3 foods which have been shown to be associated in some cases
Sulphite additives (processed foods, dried fruit, medicines, beer and wine), wine, thermal effects (cold drinks etc)
207
List at least 3 medicines which can worsen asthma
Beta blockers, anticholinesterases and cholinergics, complementary medicines such as echinacea, bee products, those containing salicylates such as willowbark
208
List 1-2 cardio selective beta blockers that may be used with extreme caution in asthma, and 1-2 which are non selective and must not be used
Cardioselective beta blockers target receptors in the heart, these include atenolol, bisoprolol, metoprolol and nebivolol. Nonselective beta blockers target both alpha-1 and beta-2 receptors, thereby having the potential to cause bronchoconstriction in the lungs. Examples include cervedilol, labetolol and propanolol
209
Give some examples of cholinesterase inhibitors that should be used with caution in people with asthma
Neostigmine, donepazil, rivastigmine, galantamine
210
List at least 1 of the 4 monoclonal antibody therapies that are available in Australia for the treatment of patients with severe eosinophilic or allergic asthma which is uncontrolled despite optimised standard treatment
Omalizumab, mepolizumab, benralizumab, dupilumab
211
Which non-pharmacological treatment is recommended for adults with asthma and mucus production?
Referral to a physio or online video to learn Active Cycle of Breathing technique
212
Bisphosphonates are recommended for primary fracture prevention in which circumstances?
Glucocorticoid-induced OP T score less than or equal to -1.5, patients with osteopenia (T score less than or equal to 1) treated with 7.5mg or more of pred/day for 3 months or more
213
Patients with severe asthma should be given what advice regarding immunisation?
Recommend annual fluvax and pneumococcal
214
Azithromycin and clarithromycin are sometimes used in the management of which chronic respiratory conditions to reduce exacerbation rates?
CF, bronchiectasis, COPD
215
Oral corticosteroid use in adults with asthma is associated with which serious adverse events? (Name at least 4)
Severe infections, peptic ulcers, affective disorders, cataracts, CV events including MI and HTN, diabetes, fractures and OP
216
For children aged 1-5 with preschool wheeze where a reliever is prescribed, when should parents be educated to give (and not give)?
Reliever should be used when wheezing episodes are associated with increased WOB. Not for cough in the absence of other symptoms, and not for noisy breathing in infants with no increased WOB
217
In children aged 1-5, quote the stepped ladder for treatment for asthma
1. SABA only, 2. Add preventer with either low dose ICS or montelukast, 3. step up to low dose ICS AND montelukast, OR high paediatric dose ICS
218
Which children aged 1-5 with preschool wheeze should be considered for preventative treatment
Those with symptoms every 4-6 months. Any child with symptoms at least once/week, or who have moderate flare ups or worse (requiring ED/oral steroids etc.) should get a preventer.
219
Quote the appropriate treatment of a reliever to prescribe to a child aged 1-5 with salbutamol responsive preschool wheeze
Salbutamol 2-4 puffs (100mcg per puff) as needed
220
For children aged 12 months to less than 2 years, consider a treatment trial with low dose ICS only if any of which 3 factors apply?
Symptoms (wheezing, cough, breathlessness) occur at least once/week and frequently disrupt sleep or play, flare ups severe enough to require ED or oral steroid, flare up that requires hospitalisation
221
List the conditions whereby montelukast may be chosen as the preventer of choice in children aged 1-5 with preschool wheeze
Unable to use or refuses MDI + spacer/mask, if significant allergic rhinitis that requires threatment, if parents decline steroid treatment
222
List at least 3 adverse effects of SABAs in children aged 1-5
Muscle tremor, palpitations, agitation (hypokalaemia at very high doses)
223
What is the step-down advice for children aged 1-5 who have had good symptom control for at least 6 months whilst on an ICS?
Reduce dose and monitor sontrol within 4-6 weeks, and do not attempt to step down treatment at the start of the preschool year or during the child's peak asthma season if this is predictable.
224
When should a 1-5 year old child with wheeze be considered for oral steroids, and what dose is appropriate?
For those with acute asthma/wheeze with increased WOB severe enough to require hospital admission. The dose is 1mg/kg prednisolone (max 50mg) each morning for 3 days
225
When should a 1-5 year old child be prescribed an oral steroid for use as part of an asthma action plan?
Never, the child always needs to be reviewed
226
In regards to management of acute flare ups in children (up to 12), what is different in the advice regarding ICS treatment when compared to adults with exacerbations?
In kids, there is no evidence to support increasing the dose or adding an ICS during exacerbations
227
When is regular preventer treatment indicated in children over 6 with asthma?
Frequent intermittent asthma (flare ups every 6 weeks or more often) or persistent symptoms (daytime asthma symptoms more than once/week or night symptoms more than twice/month) and those with severe flare ups irrespective of the frequency or symptoms between
228
Which children aged 6+ should be considered for preventative treatment?
Any child with frequent intermittent flare ups (more than once every 6 weeks without symptoms between), persistent flare ups (any of day symptoms > 1/week, night symptoms >2/month or restricting activity or sleep), and any child with at least moderate severity flare ups requiring ED/oral steroids)
229
In children aged 6+, quote the stepped ladder for treatment for asthma
1. SABA as needed, 2. Add low dose ICS OR montelukast, 3. Change to high dose ICS OR low dose ICS/LABA OR low dose ICS + montelukast
230
List and define the 3 levels of recent asthma symptom control in children
Good control (all of: daytime symptoms 2 or less times/week, rapidly relieved by SABA, no limitation of activities, no symptoms at night or on waking, SABA 2 or less days/week). Partial control (any of: day symptoms > 2 days/week, any limitation of activities, any symptoms at night or on waking, need for SABA > 2 days/week). Poor control (Either of: daytime symptoms >2 days/week lasting minutes/hours or recurring OR 3 or more features of partial control within the same week)
231
What is the step-down advice for children aged 6+ who have had good symptom control for at least 6 months whilst on a combined ICS-LABA?
Consider switching to a low dose ICS only, monitor symptom control 4-6 weeks after and do not attemp to step down at the start of the preschool year or during peak asthma season if predictable.
232
Which combination inhaler is approved by the TGA for use in children 4 years and older?
Fluticasone proprionate + salmeterol (Seretide) - though unlike in adults not shown to be associated with significant reduction in flare ups compared to ICS alone
233
For children 6+ who are suspected to have asthma, how often should spirometry be performed?
If normal, repeat annually at asthma reviews. If abnormal, check again 4-6 weeks after starting or changing treatment
234
What is the role of Tiotropium in the treatment of asthma in children?
Approved for children over the age of 6 with moderate to severe asthma, and prescribed by a specialist
235
In children over 6 who have persistent exercise induced respiratory symptoms despite regular treatment with inhaled corticosteroids, consider adding which other medication?
Montelukast (though not all children will get a response)
236
List the most common bahavioural and/or neuropsychiatric adverse effects of montelukast
Nightmares, sleep disturbance, anxiety, irritability, agrression and depression
237
What treatment is recommended for a child 6+ years who has asthma and symptoms have been well controlled for at least 6 months whilst taking a regular ICS?
Consider reducing the dose (or ceasing if already on lowest dose), and monitor symptom control with repeat spirometry in 4-6 weeks (and don't step down at start of school year or during child's peak asthma season if predictable)
238
What treatment is recommended for a child 6+ years who has asthma and symptoms have been well controlled for at least 6 months whilst taking a regular combination ICS + LABA?
Consider halving the dose. If the ICS dose is already low, replace the combination inhaler with ICS alone. Monitor symptom control in 4-6 weeks (and don't step down at start of school year or during child's peak asthma season if predictable)
239
What treatment is recommended for a chlild 6+ years who has acute asthma and is needing SABA approximately every 4 hours over a 24 hour period?
Short course of prednisolone (1mg/kg (max 50mg) each morning for 3 days
240
For children 6+ who have uncontrolled asthma, what other add-on treatment is approved for use providing that the child has been seen for at least 6 months by a specialist?
Monoclonal antibody Omalizumab
241
What advice should be given to parents for washing spacers?
Clean no more often than monthly, and after infection. Always air dry without rinsing or wiping.
242
List at least 7 risk factors for life-threatening asthma flare ups in children
Poor control, admission to hospital in past 12 months, history of intubation for acute asthma, overuse of SABA, abnormal spirometry, poor adherence to preventer or action plan, exposure to allergens or smoke, obesity, other allergies, family factors
243
Sensitisation to which allergen is almost universal in patients who have reported flare ups of asthma consistent with thunderstorm asthma in Australia?
Rye grass allergen
244
List the 2 forms of specific allergen immunotherapy available in Australia
Sublingual immunotherapy, subcutaneous immunotherapy
245
Both forms of allergen immunotherapy for asthma in Australia require what treatment duration?
3-5 years (and can be repeated)
246
True or false? Food allergy is a risk factor for life-threatening asthma flare ups
True.
247
Give one example of a validated checklist for assessing recent asthma control in children
Test for Respiratory and Asthma Control in Kids (TRACK)
248
What red flags should parents be educated to watch for in rgeards to adrenal insufficiency in a child who has required high dose ICS for 6 months or longer
Lethargy, vomiting, abdominal pain, seziures
249
What is the standard screening test for adrenal suppression in children? What is the next investigation if this is abnormal?
Morning cortisol lecel. If abormal, followed up with a low-dose adrenocorticotropic hormone stimulation test.
250
Briefly describe the recommended steps for asthma first aid for community members
Rule of 4's - Sit person upright and give 4 puffs of a reliever (4 breaths to 1 puff), wait 4 minutes and give 4 more breaths if needed
251
If a person is having an asthma attack in the community and ventolin is not available, what other puffers could be used if they were available?
Symbicort (budesonide/formoterol - ICS/LABA) or Bricanyl (terbutaline - SABA)
252
Consider an asthma action plan for adults. If the usual treatment includes a SABA only (only appropriate for symptoms < twice/month, no waking, no severe flare up within the past year, no other risk factors for severe flares), what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Start regular ICS preventer and continue for at least 2-4 weeks
253
Consider an asthma action plan for adults. If the usual treatment includes PRN budesonide-formoterol only (i.e., Symbicort - no maintenance treatment) what is the suggested first line strategy for adjusting treatment when symptoms worsen?
Increase use as needed
254
Which patients with asthma are particularly at risk of thunderstorm asthma?
Those with seasonal (springtime) allergic rhinitis (i.e., probably allergic to ryegrass pollen) and live in or are travelling to an area with high grass pollen levels.
255
List at least 3 strategies that may be helpful in avoiding pollen in patients who are sensitised to pollens
Stay indoor during and after thumderstorms, stay indoors on high pollen and windy days, wear sunglasses to prevent allergens from depositing onto the conjunctiva, wash and dry clothes inside to prevent deposition of pollen onto clean clothes, keep windows closed where possible
256
When should oxygen therapy be administered to adult vs children in acute asthma?
If <92% in adults, or <95% in children
257
Within what timeframe shouls systemic corticosteroids be given in acute asthma? What is the dose?
Within the first hour. In kids, give 1mg/kg prednisolone (assuming patient can take oral medication), in adults, give 50mg. Continue for 5-10 days.
258
Patients who present with an asthma attack should be observed for __ hours after respiratory distress/WOB has resolved
3
259
Nebulisers can generate aerosol droplets that can spread for several metres and remain airborne for more than ___ minutes
30
260
True or false? Wheezing infants younger than 12 months old should not be treated for acute asthma
True - acute wheeze in this age group is most commonly due to acute viral bronchitis
261
What is the definition of a mild flare-up/exacerbation of asthma? Provide 1 example
Worsening of asthma control that is only just outside the normal range of variation for the patient (i.e., more symptoms thatn usual, needing reliever more than usual, waking up with asthma)
262
What is the definition of a moderate flare-up/exacerbation of asthma? Provide 1 example
Events that are all of: troublesome or distressing, require a change in treatment, not life threatening, do not require hospitalisation. E.g., more symptoms than usual, difficulty breathing, waking often at night
263
What is the definition of a severe flare-up/exacerbation of asthma? Provide 1 example
Events that require urgent action by the patient (or carers) and health professionals to prevent a serious outcome such as hospitalisation or death from asthma (i.e., needing reliever again within 3 hours, difficulty with normal daily activities)
264
What is the definition of "severe asthma"?
Asthma that is uncontrolled despite treatment with a high dose of ICS in combination with a LABA (with correct inhaler technique and adherence) or maintenance oral corticosteroids, or that requires such treamtment to prevent it from becoming uncontrolled
265
If an adult patient with acute asthma has poor response to initial management with SABA +/- ipratropium, what is the next line of therapy and the dose?
Add IV Magnesium sulfate - 10mmol as a single IV solution over 20 minutes (for a child, the dose is 0.1-0.2 mmol/kg to a max of 10mmol)
266
In both adults and children presenting with acute asthma, what are the signs of mild/moderate severity on rapid primary assessment?
Can walk, speak whole sentenses in one breath, sats >94%
267
In both adults and children presenting with acute asthma, what are the signs of severe severity on rapid primary assessment?
Any of: increased work of breathing, unable to complete sentences in one breath due to dyspnoea, obvious respiratory distress, oxygen saturation 90-94%
268
In both adults and children presenting with acute asthma, what are the signs of life threatening severity on rapid primary assessment?
Any of: reduced consciousness or collapse, exhaustion, cyanosis, sats <90%, poor respiratory effort, soft/absent breath sounds
269
List at least 3 featres of salbutamol toxicity
Tachycardia, tachypnoea, metabolic acidosis, hypokalaemia
270
Explain why oxygen should not routinely be given to adults with acute asthma, when sats 95% or higher
Because over-oxygenation increases the risk of hypercapnoea
271
Give at least 3 examples of when a patient with acute asthma should be considered for adrenaline therapy
If the patient is unresponsive, cannot inhale bronchodilators or is considered to be periarrest, when anaphylaxis is suspected. Can be used in life-threatening asthma if there is no response to other bronchodilators and condition is rapidly deteriorating
272
True or false? Pregnant women presenting with acute asthma should be given salbutamol and oral steroids as indicated, just as for non-pregnant patients
True - pregnant women who present with acute asthma should receieve treatment immediatley to minimise the risk to both the foetus and woman
273
What is the main cause of death due to asthma?
Hypoxia
274
In which situations should non invasive ventilation be considered in acute asthma?
If the patient is starting to tire or develops type 2 respiratory failure
275
For a patient presenting with acute asthma, when should mechanical ventilation be used?
Respiratory arrest, acute respiratory failure that does not respons to treatment or failure to respond to NIV
276
Quote the normal HR and RR for children 5-12 years
HR 80-120, RR 20-25
277
Quote the normal HR and RR for children 12-18 years
HR 60-100, RR 15-20
278
Name 4 situations where a CXR may be considered in a patient presenting with acute asthma
If pneumonia, atelectasis, pneumothorax or pneumomediastinum is suspected
279
When should an ABG be considered for adult patients presenting with acute asthma?
If Sp02 < 92%, or if, after treatment has been initiated, any of the following are present: inability to speak due to dyspnoea, reduced consciousness or collapse, exhaustian, cyanosis, poor respiratory effort, cardiac arrythmia
280
List at least 5 reasons to consider hospital admission for both adults and children presenting with acute asthma
Similar features: hypoxia on presentation, ongoing resp distress/WOB 1-2 hours after presentation, history of ICU admission for asthma, presentation within the past 4 weeks, high use of SABA, if unable to be appropriately monitored at home. For adults, consider spirometry at 1 hour check and admit if FEV1 <60% predicted. For kids, admit if there is a concurrent confirmed food allergy (risk of death is higher)
281
What is the dose of IM adrenaline which may be given in asthma emergencies where the patient is not responding to standard treatment and whois continuing to deteriorate?
1:1000, 0.01mg/kg up to 0.5mg (0.5mL), repeat every 3-5 mins if needed
282
What examination test/manouvre may be used in adults 1 hour after presentation with acute asthma, which may be a useful indicator of adequate recovery/response to treatment?
The lie down test - ability to lie flat without dyspnoea 1 hour after prestnation may be indicative of adequate recovery and appropriate discharge from the ED
283
What dose of ICS is indicated for all adults and adolescents who have had an asthma flare up within the past 12 months?
Low dose
284
What follow up is recommended for all patients who have been discharged from hospital/ED after an acute asthma episode?
GP check up in 3 days, and comprehensive assessment in 2-4 weeks
285
List at least 4 comorbid medical conditions that may affect asthma control
Uncontrolled allergic rhinitis/thinosinusitis, GORD, obesity, nasal polyps, upper aiways dysfunction, CVD
286
Most people with asthma have what other disease process?
Allergies
287
What are the examination findings in a patient with allergic rhinitis?
Swollen turbinates, transverse nasal crease, reduced nasal airflow, mouth breathing, darkness and swelling under the eyes caused by sinus congestion
288
Describe the pattern of symptoms seen in intermittent allergic rhinitis in adults and adolescents
Either of: symptoms <4 days/week; symptoms present < 4 consecutive weeks
289
Describe the pattern of symptoms seen in persistent allergic rhinitis in adults and adolescents
Both of: symptoms present >4 days/week and present >4 consecutive weeks
290
Describe the pattern of symptoms in mild vs moderate-to-severe allergic rhinitis in adults and adolescents
Moderate-to-severe include any of: sleep disturbance, impairment of ADLs or leisure; impairment of school/work; troublesome symptoms. Mild severity is defined by the absence of all of these features
291
For adults and adolescents with mild intermittent allergic rhinitis, consider starting treatment with which medications? What if symptoms do not improve significantly within 2 weeks?
Intranasal H1 antihistamine or second generation less sedating oral antihistamine. If no improvement, switch to an intranasal corticosteroid.
292
For adults and adolescents with seasonal allergic rhinitis, what medication can be considered as an alternative to antihistamines?
Montelukast
293
What is the next line in management for adults and adolescents with allergic rhinitis who have had incomplete response to a trial of intranasal corticosteroid?
Add antranasal anithistamine and continue both
294
Which pathology should be suspected in children with allergic rhinitis which does not respond to regular intranasal corticosteroids within 4 weeks?
Adenoid hypertrophy - refer these patients
295
For children who are taking an ICS for asthma and who have persistent allergic rhinitis symptoms despite treatment with an intranasal corticosteroid, consider adding _____
Montelukast
296
Name at least 4 of the most common comorbid conditions in people with asthma
Allergic rhinitis, rhinosinusitis, GORD, mental illness, chronic infections and OSA
297
Some complementary medicines have caused serious allergic reactions in some patients with asthma. Name 3 examples.
Echinacea, bee products, garlic supplements
298
Cold air can trigger asthma symptoms due to which 2 mechanisms?
1. Response to sudden cooling of the airways 2. Reflex-mediated lower airway response to cooling of the skin or upper airways
299
What is the definition of occupational asthma?
New-onset asthma caused by an exposure to an airborne substance in the workplace (sensitiser or irritant)
300
In which situations should the possibility of COPD or asthma-COPD overlap be considered as an alternative diagnosis in patients presenting with respiratory symptoms?
Current smoker or history of smoking and age > 25, exposure to environmental tobacco or other smoke, age 55 and over, longstanding asthma
301
What is the pathogenesis of exercise-induced bronchoconstriction in non-athletes?
Occurs when ventilatory rate is high and the airways must heat and humidify a large volume of air in a short time. Dehydration of the airway leads to release of inflammatory mediators within the airway and contraction of airway smooth muscle
302
What is the pathogenesis of exercise-induced bronchoconstriction in athletes?
Probably due to chronic injury to the airway epithelium assocaited with long-term frequent prolonged high ventilation rates in the presence of environmental exposure to cold/dry air and airborne pollutants
303
What is the usual timing of symptoms in exercise-induced bronchoconstriction in patients with asthma?
Symptoms usually worst 5-10 minutes after stopping exercise, rather than during
304
What are the symptoms of exercise-induced bronchoconstriction?
Cough, wheeze, feeling tight in the chest, breathlessness, excessive mucus production
305
Name 2 appropriate treatment options for adults/adolescents with asthma who have symptoms less than twice/month and no risk factors for flare ups, who do not use an ICS but who give symptoms consisted with exercise-induced bronchoconstriction
1. Salbutamol 1-4 puffs 15 minutes before exercise, 2. Switch to PRN low dose budesomide-formoterol (symbicort) instead of as needed salbutamol
306
Name the 2 forms of occupational asthma
1. Sensitiser-induced occupational asthma (allergic mechanism) 2. Irritant-induced occupational asthma (non-alergic mechanism)
307
What is the clinical definition of COPD?
Persistent airflow limitation resulting from a combination between small airways disease and elvolar destruction
308
Not all patients with COPD have a history of smoking. Name 5 other risk factors for development of COPD
Exposure to tobacco smoke, prenatal smoking, preterm birth, respiratory illneses in childhood, asthma, occupational exposure to dust and fumes, genetic susceptibility
309
Name the 5 main symptoms that are suggestive of COPD
Breathlessness, cough, sputum production, wheeze, recurrent respiratory tract infection
310
What spirometry finding is diagnostic of COPD?
Post bronchodilator FEV1/FVC ratio less than 0.7
311
All patients with COPD can benefit from which 5 general management measures?
Stopping smoking, physical activity, immunisation, pulmonary rehabilitation and good nutrition
312
True or false? Pharmacological treatment of COPD improves mortality
False. Drug treatment improves symptoms and QOL, and reduces frequency of exacerbations, but the affect on mortality remains unclear
313
Describe the step up therapy in COPD
SABA, then LABA or LAMA monotherapy, then LAMA plus LABA dual therapy, then triple therapy with LAMA.LAMA/ICS
314
ICS therapy can be added to LAMA+LABA therapy in COPD, only when which 2 criteria are met?
1. Severe exacerbation requiring hospital admission or at least 2 moderate exacerbations in the past 12 months 2. significant symptoms despite dual therapy with LAMA + LABA
315
What is the only intervention shown to improve the natural history/slow the progression of COPD?
Smoking cessation
316
Which is currently the only LABA available on the PBS for monotherapy step 2 of COPD treatment?
Indaceterol 150mcg (Onbrez Breezhaler)
317
In COPD, triple therapy with LAMA/LABA/ICS is only required in which group of patients? Why?
Those who have continued symptoms and exacerbations despite dual therapy with a LAMA/LABA. This is because ICS are associated with increased risk of pneumonia in COPD patients, so the risks vs benefits need to be carefully weighed up
318
True or false? All patients with suspected asthma/COPD overlap should be referred for Specialist management
True - these patients have more rapid disease progression and require specialist management, the evidence is limited and approaches differ
319
Patients with COPD have increased risk of which other major medical conditions? Name at least 4
CVD, diabetes, osteoporosis, anxiety with panic attacks and depression, pulmonary hypertension and cor pulmonale
320
Cor pulmonale should be considered in a patient with COPD who has any of which 4 features?
Peripheral oedema, raised JVP, systolic parasternal heave, loud pulmonary second heart sound
321
How is exacerbation of COPD characterised clinically?
By an acute worsening of symptoms, beyond normal day-to-day variations including: increase dyspnoea, reduced exercise tolerance, tachypnoea, increased cough frequency, increased sputum volume or purulence, fever, right heart failure manifesting as ankle oedema
322
List at least 4 triggers for COPD exacerbations
Viral and bacterial infections, environmental pollutants, heart failure and PE, pscyhosocial stressors
323
What is the dose of salbutamol in COPD exacerbation?
8 puffs (or 2.5mg to 5mg if nebulised)
324
True or false? A COPD exacerbation that does not fully resolve with salbutamol may improve with the addition of ipratropium
True.
325
Which treatment is recommended for COPD exacerbation that does not respond sufficiently to inhaled bronchodilators?
5 day course of systemic steroids (30 - 50mg)
326
Antibiotics should only be used in COPD exacerbation if all of which 3 features are present?
Increased sputum purulene, increased sputum volume or change i colour, fever
327
What treatment is recommended for patients with COPD exacerbation who have hypercapnic respiratory failure and acidosis?
NIV
328
In what timeframe should patients see their GP for review after being discharged from hospital with asthma and COPD exacerbations, respectively?
Asthma 3 days, COPD 7 days
329
The duration of a COPD exacerbation is related to which other factor?
The severity of the underlying COPD (for mild COPD, exacerbations can last 7-10 days, for more moderate or severe underlying disease can last weeks)
330
Explain why the doses of amoxicillin and doxycyclin used in the treatment of COPD exacerbation (presuming indicated) are smaller than those used for CAP
Because the aim of Abx in COPD is to hasten recovery rather than eradicate the bacteria, since most COPD patients will be colonised.
331
State the appropriate antibiotic treatment in exacerbation of COPD when indicated
Always oral, whether in community or hospital. Amoxicillin 500mg 8 hourly for 5 days (or 1g 12 hourly if BD dosing is more convenient) OR doxycyclin 100mg daily for 5 days.
332
What does COPDX stand for?
C - case finding and confirm diagnosis. O - Optimise function. P - prevent deterioration. D - develop a plan of care. X - manage eXacerbations
333
What are some of the recommendations in the 'O' of COPDX
Optimise function - relates to optimising pharmacotherapy in stepwise approach, checking adherene and technique, referring for pulmonary rehab and advising about exercise, managing comorbid conditions and considering pall care early
334
What are some of the recommendations in the 'P' of COPDX
Prevent deterioration - stop smoking, prevent eacerbations, vaccination, consider mucolytics, consider long term O2 therapy for survival benefit in hypoxic patients
335
What are some of the recommendations in the 'D' of COPDX
Develop a plan of care - anticipate wide range of needs, consider multiD input and self-management support as well as community groups and services
336
What are some of the recommendations in the 'E' of COPDX
Manage exacerbations - early diagnosis and treatment to prevent hospital admission and progression, multiD care may assist in home management, use NIV for patients with rising PaCO2 levels, consider pulmonary rehab at any time, ensure comprehensive follow up
337
What is the first step in the diagnosis of COPD?
Comprehensive history and examination
338
Which test is useful for determining the impact of COPD on symptoms and wellbeing?
CAT - COPD assessment test
339
What are the 5 most prevalent comorbidities in patients with COPD?
Hyperglycaemia, atherosclaerosis, hypertension, dyslipidaemia and osteoporosis
340
What is the greatest risk factor for further exacerbation in COPD?
History of exacerbation within the past 12 months
341
What is the recommended course of pneumococcal vaccination in COPD pateints who have never had one prior?
First dose to be given at diagnosis, followed by up to 2 additional doses
342
What is the recommended course of pneumococcal vaccination in COPD patients who have had an age-appropriate first dose?
Give a singe revaccination dose a minimum of 5 years following the first dose
343
What is the clinical definition of hypoxaemia on ABG?
Pa02 <55, or less than 59 with polycythaemia, pulmonary hypertension or right heart failure
344
What is the definition of ILD?
Heterogenous group of disorders that are characterised by varying degrees of fibrosis and inflammation in lung parenchyma
345
True or false? Resting hypoxia is common in ILD
False. Hypoxia with exercise is common, but resting hypoxia is a sign of advanced disease
346
What is the purpose of both inspiratory and expiratory CT series in the investigation of ILD?
Allows for detection of gas trapping or 'mosaicism'
347
What is considered to be the gold standard for diagnosing ILD
MultiD discussion between an ILD physician, radiologist and pathologist
348
What investigations are done at baseline in the workup of ILD?
CXR, high res CT, pulse oximetry and ABG, connective tissue disease serology, lung function tests inc. CLCO, 6. minute walk test
349
What are the possible findings of ILD on CXR?
Non specific infiltrates
350
What are the possible findings of ILD on high res CT?
Nodules, cysts, ground glass change, honeycomb change, traction bronchiectasis, intralobular septal thickening
351
What are the spirometry findings in ILD?
Low FEV1, low FVC, normal to high FEV1/FVC ratio, reduced lung volumes, reduced DLCO
352
List the 4 major subtypes of ILD
Idiopathic interstitial pneumonias, granulomatous ILD, ILD with known associations, miscellaneous
353
What is different about the pathogenesis of idiopathic pulmonary firosis compared to the other subtypes of ILD?
Seems to arise from fibrosis, whereas others start with inflammation and then fibrosis
354
List at least 4 common comrbid conditions in ILD
GORD, osteoporosis, infections, sleep disordered breathing, pulmonary hypertension
355
List the 3 most common subtypes of non small cell lung cancer
Adenocarcinoma, squamous cell (epidermoid) carcinoma, large cell undifferentiated carcinoma
356
If examination, CXR and spirometry are normal, state the 3 most common diagnosis for chronic cough in adults
Asthma, rhinosinusitis, GORD
357
If examination, CXR and spirometry are normal, state the 2 most common diagnosis for chronic cough in children
Protracted bacterial bronchitis, asthma (if other symptoms present)
358
What cancer is the leading casue of cancer death in Australia?
Lung cancer (the 5th most common cancer overall)
359
Under what conditions can a GP directly order a Medicare rebated sleep study (home or lab) without the patient first neeting a clinical review by a Specialist?
Must have positive OSA screening questionaire (OSA50 greater than or equal to 5 or STOPBANG greater than or equal to 4) AND ESS greater than or equal to 8
360
Which clinical finding would be more consistent with an atypical pneumonia than with a lobar pneumonia? Fever; wheeze; chest pain; tachycardia; cough?
Wheeze
361
The absence of what clinical sign makes pneumonia in a child very unlikely?
Tachypnoea
362
Which is the most likely pathogen to cause pneumonia in a 2 year old child? bordatella pertussis; haemophilus influenzae; respiratory syncitial virus; strep pneumoniae; mycoplasma
RSV - viruss are the most common cause of CAP in children oder than 2 months
363
A 55 yo woman presents with fever, chest pain, increasing SOB and dry cough. PMHx RA, on MTX. She has bibasal inspiratory crackles and CXR shows diffuse infiltrative pattern. What is the most likely diagnosis?
Drug induced pneumonitits
364
True or false? The ESS is a good marker of OSA
False, but it does predict response to treatment
365
Bacterial CAP in children is most commonly caused by which pathogen?
Strep pneumoniae
366
Name the 3 complications of staph pneumonia in children
Empyema, lung abscess, large parapneumonic effusion
367
What is the antibiotic of choice for treating mild and moderate CAP in children?
Amoxicillin 25mg/kg 12 hourly
368
Which antibiotics may be added to amoxicillin for children with CAP where atypical pneumonia is suspected?
Azithromycin 10mg/kg daily, or doxy or clarithro
369
What is the IV antibiotic of choice for children with severe CAP?
Cefotaxine 50mg/kg up to 2g TDS (or ceftriaxone 50mg/kg up to 2g daily)
370
Name at least 3 occupational exposures, aside from cigarette smoking, that are associated with increased risk of lung cancer
Radon, asbestos, diesel exhaust, silica
371
A 27 yo presents with a 3 day history of fever, headache, fatigue and persistent cough. The cough has slowly become worse and is incessant. O/E she appears well and temp is 37.8. CXR shows diffuse bilateral infiltration. Which is the most likely infective organism? Haemophilus, legionalla, mycloplasma, pseudomonas, strep pneumoniae?
Mycoplasma pneumoniae
372
Describe the clinical presentation of mycoplasma pneumoniae
Low grade fever, headache and cough are prominant. May be normal on examiantion in early illness, but rhonchi, rales or wheeze can be seen several days later. CXR findings are usually more striking than examination findings
373
List at least 5 groups of inviduals deemed to be at higher risk of poor outcomes from influenza
Adults > 65 years, pregnant women, people with: (heart disease, down syndrome, obesity > 30 BMI, chronic resp illness, sereve neurological conditionals, immune compromise), ATSI of any age, children 5 or younger, RACF patients, homeless people
374
A 45 year old previously fit farmer presents with SOB, cough, lethargy and fever. O/E he is febrile, mildly tachypnoeic and has crepitations in the left lung base. What is the most likely organism to account for his clinical findings?
Strep pneumonia - for garden variety CAP
375
In pregnant women with suspected PE who also have symptoms and signs of DVT, what is the first recommended investigation?
Compression dupex US - if DVT is confirmed, no further investigation is required and treatment for VTE should continue
376
In pregnant women with suspected PE who do not have symptoms and signs of DVT, what is the next step in investigation?
V/Q scan or CTPA should be performed
377
What is the resting threshold oxygen saturation at room air as measured by pulae iximeter that required supplemental oxygen in flight?
SpO2 < 88%
378
What factors need to be met for a COPD patient to be considered for long term oxygen therapy?
Those with stbale disease and hypoxaemia, who has ceased smoking for at least 1 month and potentially reversible factors are treated
379
Describe the clinical presentation and course of pertussis
Initial catarrhal phase wth insidious onset runny nose, low/absent fever, mild cough. Cough slowly becomes paroxysmal after 1-2 weeks and may end in vomiting, cyanosis and/or insi]piratory whoop. Fever general minimal throughout
380
What are the common symptoms of legionaires pneumonia
Fever, cough, chest pain, breathlessness and diarrhoea
381
What is hypersensitivity pneumonitis?
AKA extrinsix allergic alveolitis - diffuse, granulomatous inflammation of the lung parenchyma and airways in people who have been sensitised by repeated inhalation of organic antigens in dusts (daily or grain products, animal dander etc)
382
Give some examples of hypersensitivity pneumonitis, depending on the source
Farmer's lung (mouldy hay), bird fanciers lung (avian proteins), cheese workers lung (cheese mould), hot tub lung
383
Describe the presentation of acute hypersensitivity pneumonitis
Start within 4-8 hours of exposure and resolve rapidly. Symptoms similar to pneumonia with dry cough, bibasal inspiratory crackes on auscultation
384
Describe the presentation of subacute hypersensitivity pneumonitis
Insidious onset, productive cough, dyspnoea, fatigue, weight loss, may be a history of recurrent acute pneumonitis
385
What is normall seen on CXR of hypersensitivity pneumonitis
Micronodular opacities in the mid/upper lung fields. If chronic, may see fibrosis with loss of lung volume
386
What is the treatment for hypersensitvitiy pneumonitis?
Avoidance of the allergens, sometimes corticosteroids in severe cases
387
List at least 3 complications of hypersensitivity pneumonitis
Spontaneous pneumothorax, pulmonary fibrosis, COPD, respiratory failure, cor pulmonale
388
How is bronchiectasis characterised both morphologically and clinically?
Morphologically by dilatation of bronchi and bronchioles and clinically by recurrent bronchial infection and chronic cough with sputum. Can also present with fatigue, breathlessness and pleuritic chest pain, with course crackles on auscultation. Can have clubbing
389
What is the pathogenesis of bronchiectasis?
Related to chronic airway infection and inflammation, resulting in airway damage
390
What is the most common cause of bronchiectasis?
Pneumonia, often in childhood
391
List at least 3 common causes and contributors to bronchiectasis, as well as 3 less common/rare causes
Common: severe resp illness, asthma, COPD, CF. Less common include GORD, RT, connective disuse disease, IBD, alpha 1 anti trypsin deficiency
392
Which disease process should always be considered in patients presenting with coarse crepitations, chronic productive cough and recurrent or difficult to treat chest infections?
Bronchiectasis
393
What is the gold standard for diagnosis of bronchiectasis?
High rest CT
394
Antibiotics should only be used in exacerbations of bronchiectasis when all of which 3 criteria are present?
Increased sputum volume or change in viscosity, increased sputum purulence, increased cough (may be associated with wheeze, dyspnoea or haemoptysis)
