Respiratory

Question 1

Features severe asthma exacerbation

Answer 1

Peak flow 33-50% predicted
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RR>25
HR>110
Sats>92%

Question 2

Features life threatening asthma exacerbation

Answer 2

Peak flow <33% predicted
Sats<92%
Silent chest, cyanosis, or poor respiratory effort
Arrhythmia or hypotension
Exhaustion, altered consciousness

Question 3

Risk factors severe asthma

Answer 3

Prev ICU/admissions
3+ classes of medication
High use SABA?3x per week
Non compliance/psychosis
Smoking

Question 4

Management acute exacerbation asthma

Answer 4

O2, salbutamol nebs, admit

If mild:
5-10 puffs salbutamol using tidal breathing + aerochamber
prednisolone 40mg OD 5 days
+/- amoxicillin 500mg TDS 5 days

Quadruple inhaler ICS dose until recovered

Question 5

How do you diagnose asthma in adults with spirometry?

Answer 5

If pre BD spirometry shows obstruction (FEV1/FVC ratio <0.7) perform reversibility with SABA
12% (and >200mls) increase in FEV1

Question 6

How do you diagnose asthma in adults with peak flow diary?

Answer 6

Complete 2-4 week peak flow diary
Evidence of 20% peak flow variability supports asthma diagnosis.
Once on treatment with ICS expect peak flow to increase and variability reduce

Question 7

How do you diagnose asthma in adults with FeNO?

Answer 7

FeNO >40 consistent with
asthma (steroid naive)

Question 8

Triggers for asthma exacerbation

Answer 8

Allergens- hayfever, rhinitis
Exercise
Cold air
Medications, e.g. aspirin and beta blockers
Occupational
Viral infections

Question 9

6 questions to assess asthma control

Answer 9

Nocturnal disturbance- woken with coughing and wheezing?
Impact on ADLs
Cough, wheeze, chest tightness, breathlessness, during the day?
Reliever therapy use
Concordance with preventer use
Use of PO corticosteroids

Question 10

1st step asthma management in adults

Answer 10

ICS+immediate acting LABA as MART regime
Symbicort Turbohaler 200/6
1 dose PRN up to 8 doses/day

Question 11

Step 2 asthma management adults

Answer 11

MART regime:
Symbicort Turbohaler
200/6, 1 puff BD
Max doses/day: 12

Fostair NEXThaler
100/6, 1 puff BD
Max doses/day: 8

Trial montelukast 10mg at night 6 weeks

Question 12

Step 3 asthma management adults

Answer 12

MART regime:
Symbicort Turbohaler
200/6, 2 puff BD
Max doses/day: 12

Fostair NEXThaler
100/6 2 puffs BD
Max doses/day: 8

Trial montelukast 10mg at night 6 weeks

Question 13

Step 4 asthma management in adults

Answer 13

Continue MART regime + LAMA
Add on Spiriva Respimat
2.5mcg 2 doses OD

Question 14

Step 5 asthma management adults

Answer 14

Referral ?biologics
Symbicort Turbohaler
400/12, 2 doses BD + spiriva respimat 2.5mcg 2 doses OD

Question 15

When would you refer adults with asthma?

Answer 15

-Diagnostic uncertainty
* Complex comorbidity
* Suspected occupational asthma
* Poor control following treatment at Step 4
* ≥2 courses of oral steroids/ year

Question 16

Step 1 children with asthma

Answer 16

Age<6
Clenil 100mcg 1 dose BD + SABA PRN (with spacer)

Age 6-11
Budesonide100mcg Turbohaler 1 dose BD + SABA PRN (Terbutaline 500mcg Turbohaler)

Age>12
Budesonide 100mcg Turbohaler 1-2 doses BD + SABA PRN (Terbutaline 500mcg Turbohaler)

Question 17

Step 2 children with asthma

Answer 17

Age<6
6 week trial montelukast 4mg ON

Age 6-11
6 week trial montelukast 5mg ON

Age>12
6 week trial montelukast 5mg ON or 10mg if age>15

Question 18

Step 3 children with asthma

Answer 18

Age<6 refer, mod dose ICS + SABA Clenil modulite 100 mcg
2 doses BD via spacer

Age 6-11
ICS/LABA plus PRN SABA
Symbicort 100/6 Turbohaler 1 dose BD

Age>12
Adult MART Symbicort 100/6 Turbohaler 1 dose BD
(max 8 doses/24 hrs) + emergency SABA

Question 19

Step 4 children with asthma

Answer 19

Age<6 Refer

Age 6-11
Refer
ICS/LABA Mod Symbicort 100/6
Turbohaler 2 doses BD

Age>12
MART Symbicort 200/6
Turbohaler 1-2 doses BD
(max 8 doses/24 hrs)

Question 20

Diagnosis asthma in children

Answer 20

Peak flow diary (1-2 week) age 5-17
Skin prick test, Allergen-specific IgE, Blood eosinophils age 3-17
Spirometry with reversibly testing age ≥ 12
Fractional exhaled Nitric Oxide (FeNO) age ≥ 12

Question 21

If no objective evidence but strong clinical suspicion asthma in children?

Answer 21

Perform treatment trial
Including in children age 3-5 years
with “episodic wheeze”:
* Commence ICS for 8 weeks: Clenil
modulite 200mcg BD
* Review response at 8 weeks

No response
- Discontinue treatment
- Consider alternative diagnosis
Positive response
- Discontinue treatment
- If symptoms recur, restart low dose
ICS as maintenance therapy

Question 22

How to differentiate asthma from COPD

Answer 22

Asthma: response to SABA>200 mL and >12% improvement of FEV1.

Completely reversible airway obstruction do not have COPD

If a patient with a high clinical suspicion of asthma, consider a trial of 40 mg of prednisolone OD for 2 weeks, then repeat spirometry.

Question 23

Features bronchiectasis

Answer 23

Permanent abnormal dilatation of the airways
Impaired mucociliary clearance
Excessive inflammation of airways, mucus production, and bacterial colonisation.

chronic productive cough.
unexplained haemoptysis
Exertional dyspnoea
Recurrent chest infections
Signs of over-inflation of chest
Finger clubbing (now rare)
Pseudomonas on sputum culture

Question 24

Underlying causes bronchiectasis

Answer 24

Post TB, Measles, pertussis, pneumonia
Cystic fibrosis
COPD
IBD, RA

Question 25

Diagnosis of bronchiectasis

Answer 25

CXR to exclude other causes Spirometry Sputum High resolution CT when well

Question 26

Referral criteria bronchiectasis

Answer 26

first isolate of Pseudomonas aeruginosa, or atypical mycobacteria. persistent haemoptysis. spirometry shows moderate to severe airflow obstruction or declining lung function over time. recurrent exacerbations (>3 per year) known immune deficiency, IBD, RA, or allergic bronchopulmonary aspergillosis (ABPA). considering long‑term antibiotic therapy.

Question 27

CRB-65

Answer 27

Confusion RR>30 BP: Systolic <90 or Diastolic <60 Aged 65 years or older If >1 then admit

Question 28

Ix for LRTI

Answer 28

Treat empirically/based on prev sputum for 72 hrs If no improvement: CXR, bloods, sputum culture, consider admission

Question 29

Features COPD

Answer 29

airflow obstruction on spirometry, and a history of smoking, or exposure to other noxious agents. cough up phlegm or mucus most days. lose breath more easily than others their age. suffer recurrent episodes of winter chest infections.

Question 30

COPD findings on spirometry

Answer 30

Reduced FEV1 (<80% predicted) Reduced FVC (but to a lesser extent than FEV1) FEV1/FVC ratio reduced (<0.7) Mild – FEV1 more than 80% predicted Moderate – FEV1 50 to 80% predicted Severe – FEV1 30 to 50% predicted Very severe – FEV1 less than 30% predicted

Question 31

Non inhaler management COPD

Answer 31

Vaccination (flu, COVID, pnuemococcal) Exercise + pulmonary rehab Smoking cessation Referral for oxygen assessment if SpO2 is <93% and not smoking Mucolytic – carbocisteine 750 mg twice a day.

Question 32

COPD management

Answer 32

Phenotype 1- Dyspnoea with less than 2 exacerbations per year LABA + LAMA (Anoro Ellipta 55/22 T OD) Phenotype 2- Two or more exacerbations per year Prescribe Triple therapy (trelegy OD, trimbow BD) Phenotype 3- asthma overlap Significant symptomatic or lung function response to steroids. Blood eosinophil counts >0.3 MART plus LAMA (symbicort turbohaler 200/6 TT BD + spiriva respimat TT OD)

Question 33

COPD exacerbation management

Answer 33

SABA PRN Prednisolone (30mg OD 5 days) Abx if increased sputum purulence, volume + breathlessness

Question 34

Referral criteria COPD

Answer 34

diagnostic uncertainty. patient younger than 40 years, or younger than 55 years with severe disease. >2 exacerbations a year. considering pulmonary rehabilitation. considering nebulised therapy

Question 35

Differential diagnoses for cough

Answer 35

Asthma Gastro‑oesophageal reflux –worse lying down to sleep, after meals, dysphonia. Postnasal drip Malignancy – weight loss, dysphonia, dysphagia ACEi Cardiac – dyspnoea, palpitations, ankle swelling.

Question 36

Cough>8 weeks

Answer 36

USC referral if unexplained haemoptysis or weight loss/hoarseness CXR Consider sputum culture x3 (MC+S, acid‑fast bacilli, and fungi) Consider spirometry Treat underlying cause (eg trial nasal steroid, asthma treatment, PPI)

Question 37

Causes haemoptysis

Answer 37

lung cancer. TB bronchiectasis pulmonary abscess. Minor haemoptysis: LRTI PE anticoagulant or antiplatelet treatment. CCF/ mitral stenosis – pink frothy

Question 38

Risk factors for TB

Answer 38

Close contacts active TB Migrants Age<5/Elderly Immunosuppressed, HIV, diabetes Misusing drugs or alcohol Homeless or in overcrowded housing Prison leavers

Question 39

ILD causes

Answer 39

Idiopathic RA/Sarcoid Asbestosis/silica Chemo, nitrofurantoin

Question 40

Features OSA

Answer 40

STOP BANG Snore loudly Tired/fatigued Stopping breathing during sleep HTN BMI>35 Age>50 Neck circumference>40cm Male