Respiratory3

Question 1

Treatment of acute bronchitis?

Answer 1

1. Educate patient on the self limiting nature of illness - explain that cough lasts 2-3 weeks and 90% have cough resolution by 4 weeks. 2. Prescribe paracetamol for fever (sympto mx) 3. Prescribe NSAID for pain (sympto mx) 4. SAFETY NETTING Review if new-onset fever, difficulty breathing, symptoms last greater than 3 to 4 weeks, or bloody sputum 5. If cough persists for more than 8 weeks, need to investigate for causes of chronic cough

Question 2

Definition of acute bronchitis?

Answer 2

SELF LIMITING lower respiratory tract infection involving the large airways, WITHOUT EVIDENCE OF PNEUMONIA, that occurs in the ABSENCE OF COPD

Question 3

Definition of chronic bronchitis?

Answer 3

Subset of COPD Cough lasts for more than 3 months in 2 consecutive years

Question 4

What are the STOP BANG questions for sleep apnoea?

Answer 4

S - snoring?

T - tired?

O - observed apnoeas?

P - high blood pressure

B - BMI over 35

A - Age over 50

N - neck circ - over 40 cm

G - gender - Male

Medicare cut off for high risk = 4 (more specific and less sensitive than 3 - will miss some positives but more likely that a positive is true!)

Question 6

What is the AHI?

Answer 6

Apnoea/Hypopnea index - measures the average number of respiratory disturbances per hour of sleep

Question 7

What is OSA in terms of AHI (and severity)

Answer 7

AHI greater than or equal to 5 is OSA (mild)

Over 15 - moderate

Over 30 - severe

Question 8

Whats the problem with screening questionnaires in OSA

Answer 8

Highly sensitive - but when used alone are poorly specific for moderate-severe OSA

negative questionairres dont exclude OSA or another sleep disorder

Question 9

How good is ESS as a predictor of OSA

Answer 9

Poor predictor

BUT

if elevated - does predict response to treatment

Question 10

Risk factors for OSA

Answer 10

obesity,

adenotonsillar hypertrophy (mainly seen in children and young adults),

increasing age,

type 2 diabetes,

alcohol and sedative use,

and hypertension that is difficult to control

Question 11

Presenting symptoms of OSA

Answer 11

1. Their own daily symptoms:

• unrefreshing sleep,
• tiredness and fatigue,
• poor concentration and focus,
• a low mood
• or excessive daytime sleepiness.

2. They may be suspicious that they have OSA (eg because of apnoeas witnessed by their partner) and are concerned about the potential adverse health consequences.

• immediate problems such as safety driving
• or worry about more long-term concerns such as cardiovascular disease, stroke or cognitive decline.

Finally, their concerns may relate more to the effect on their bed partner. Socially disruptive snoring with or without witnessed apnoeic episodes is a common initial trigger symptom that should lead to questioning about the other symptoms listed above.

Question 12

What is the OSA50 questionairre

Answer 12

Obesity - waist circ over 102 cm for males and 88cm for females

Snoring -has anyone ever told you you snore

Apnoeas - has anyone noticed that you stop breathing during sleep

50 - age over 50

Greater than equal to five is 94% sensitive for moderate to severe OSA

Question 13

What are the OSA questionairre numbers you need before being able to directly refer a patient for a PSG?

Answer 13

1. OSA50 greater than or equal to 5

OR

• Positive BQ

OR

• STOPBANG greater than or equal to 4

AND

2. ESS greater than or equal to 8

(High Pre-test probability of OSA)

Question 14

When would you refer a patient with OSA to sleep physician?

Answer 14

• Mod-severe OSA (AHI over 15)
• Mild OSA with significant symptoms
• Driving Risk

Question 16

Does ESS correlate well with AHI?

Answer 16

NO

thats why you need other questionairres as well

Question 17

What are important factors to consider during a clinical assessment for a patient with OSA?

Answer 17

Signs of adenotonsillar hypertrophy. - potential surgical treatment for OSA?

Driving and workplace safety. commercial drivers or other safety-critical workers – or if sleepiness while driving – assess urgently and advice about driving risk provided - yearly sleep physician review if commercial driving license. Use CPAP with a usage meter to measure compliance.

Obesity. THE major reversible risk factor for OSA, OSA symptoms commonly develop in conjunction with a period of rapid weight gain.

Hypertension. OSA is associated with hypertension, and (CPAP) may improve blood pressure control,

Depression. commonly co-exists with OSA and shares similar symptoms of tiredness, fatigue, sleepiness and poor motivation. Depression is also a risk factor for an incomplete response to CPAP treatment and may need to be independently addressed

Question 18

Causes of daytime sleepiness?

Answer 18

1. Insufficient night time sleep (quantity)
2. Poor quality sleep (quality)
3. Other conditions

a) Depression b) Sleep disorders - OSA, central and peripheral, narcolepsy, hypersomnia, limb movement disorder c) Thyroid disorder d) anaemia

Question 19

Whats the pathophys of OSA

Answer 19

Apnoea/hypopnea

hypoxia and hypercapnia

leads to respiratory acidosis

Arousal from sleep

Breathes and cycle resumes

Cycle lasts 15seconds to 1.5 minutes

Question 20

Causes of OSA?

Answer 20

1. Narrow nose/obstruction
2. Airway narrowing - enlarged adenoids/obesity
3. Low muscle tone - Downs/Alcohol/Sedatives

Question 21

Examination findings in OSA

Answer 21

1. BMI
2. Waist circumfernece
3. Neck circumference.
4. Blood pressure
5. Upper Airway Anatomy - Mallampati score

Question 22

What are the classes of the Mallampati score

Answer 22

Question 23

What is the management of OSA?

Answer 23

1. Weight reduction
2. Stop ETOH and sedative meds before sleep
3. Increase time in bed
4. Positional therapy (side vs supine)
5. Reduce Nasal resistance - smoking cessation, may need surg correction, or intranasal corticosteroid for six weeks
6. GOLD STANDARD is CPAP
7. Mandibular advancement splints in mild to moderate - needs dental review and monitoring
8. Surg - mainly for craniofacial abnormalities - doesnt usually change AHI

Question 24

What are some complications of CPAP and how would you manage them?

Answer 24

1. Nasal symptoms due to dry air - HUMIDIFIER (built in or add on to machine), intranasal corticosteroid spray
2. Mouth leak - CHIN STRAP
3. Dry mouth - usually indicates mouth leak - try chin straps (humidification wont help if theres a leak) - can also reduce pressure of cpap
4. Skin ulceration over nasal bridge - usually too tight (Re-fit with cpap therapist)
5. Ear discomfort - corticosteroid nasal spray

Question 25

How can you improve adherence to CPAP therapy?

Answer 25

1. Ensure comfortable mask 2. humidification needs to be operational 3. no anatomical obstruction requiring surg intervention (eg chronic nasal injury or secondary obstruction) 4. Exclude comorbidities or other lifestyle/psych factors 5. Provide encouragement CONSIDER = use while distracted, use on alternate nights, short course of anxiolytic drugs for one week at initiation

Question 26

Whats the advantage of automatically titrating CPAP?

Answer 26

**Treatment can commence immediately** - automatically adjusts pressure delivered so you don't need a second sleep study to determine optimal pressure to use.

Question 27

What is the gold standard for measuring sleep stages and quantifying respiratory events?

Answer 27

IN LAB PSG

Question 28

What does an in lab PSG test?

Answer 28

multiple physiol variables to measure sleep architecture and cardioresp function. These include: EEG, EMG, EOG (ocular) bilaterally, ECG, arterial O2 sats, nasal airflow, body position, sound, respiratory movements,

Question 29

When are home based PSGs useful?

Answer 29

Can be used if there's a high pre-test probability They are specific but not sensitive So they can rule a positive OSA test in but can't rule a negative OSA test out (could still be OSA) SO if suspicious patient gets a negative home PSG they still need an in lab

Question 30

Complications of OSA

Answer 30

1. Motor vehicle accidents 2. Pulmonary hypertension 3. Cardiovacsular disease (incl AF) 4. Factors associated with Metabolic syndrome 5. Neurophsych dysfunction

Question 31

Definition of pneumonia

Answer 31

Infection of pulmonary parenchyma ( pathogens at alveolar level)

Question 32

Causes of Community Acquired pneumonia?

Answer 32

1. Strep pneumonia 2. Chlamydia Pneumonia 3. Mycoplasma pneumonia (prolonged, can have prominent constitutional, young adults) 4. Legionella 5. Heamophilus influenzae in COPD pts 6. Staph Aureus and Klebsiella (Severe) 7. Coxiella Burnetii 8. Burkholderia pseudomallei and Acenitobacter baumanii

Question 33

IN CAP how often is a) no organism identified b) multiple orgs

Answer 33

30-50% NO org id'd 20% multiple

Question 34

RF's for CAP

Answer 34

1. Age under 16 or over 65 2. COPD or bronchial Ca 3. Co-morbidities - DM, CKD, HF, Pulm congestion, viral infection, malnutrition/debility, hyposplenism, nephrosis or complement deficiency 4. Smoking, ETOH, IVDU 5. Viral infections

Question 35

DDx for cavitating lung lesion

Answer 35

Question 36

Treatment of Community acquired pneumo?

Answer 36

Usually Monotherapy with either: amoxicillin 1 g orally, 8-hourly; five days if improving after 2, otherwise one week. Or Doxy 100 bd

Question 37

When would you do dual therapy for CAP

Answer 37

If concerned that follow up in 48 hours wont occur Usu Amoxil 1g tds and Doxy 100mg bd

Question 38

Red flags for hospitalisation in CAP?

Answer 38

Patients with any of the following parameters need close clinical observation, and are therefore likely to need inpatient management: tachypnoea (**respiratory rate 22** breaths/minute or more) heart rate higher than **100 beats/minute** hypotension (**systolic blood pressure lower than 90 mmHg)** acute-onset **confusion** oxygen saturation **lower than 92% on room air** (or lower than baseline in patients with comorbid lung disease) **multilobar involvement on chest X-ray** blood **lactate concentration more than 2 mmol**/L [NB3].

Question 39

Should you culture sputum in pneumonia?

Answer 39

If a sputum sample can be collected before starting antibiotic therapy, sputum Gram stain and culture can indicate the likely pathogen (up to 40% yield), provided good quality samples (presence of polymorphs, but few or no squamous epithelial cells on microscopy) are collected. **_Always correlate the results of culture with the Gram stain._**

Question 40

Whats the role of NAAT in CAP?

Answer 40

The primary aim of NAAT (eg PCR) in the context of patients with CAP is to confirm or exclude a viral diagnosis (eg influenza) and aid decisions on antiviral therapy.

Question 41

When would you do a venous blood gas in CAP?

Answer 41

Venous blood gas analysis to estimate **blood lactate and pH** can help to assess pneumonia severity; however, venous blood gas analysis is not accurate for assessing gas exchange (eg arterial partial pressure of oxygen [PaO2] and partial pressure of carbon dioxide [PaCO2]).

Question 42

When is an arterial blood gas helpful in CAP?

Answer 42

Arterial blood gas analysis is appropriate for patients with high-severity CAP, hypoxaemia or comorbid lung disease.

Question 43

When would a pneumococcal urinary antigen be performed

Answer 43

Consider this test in **_hospitalised_** adults either with high-severity CAP, or when therapy will be altered by a positive result and results are tied to a stewardship strategy of antibiotic de-escalation.

Question 44

Which subtypes of legionella are detected by the urinary legionella antigen test? When is it used?

Answer 44

Legionella pneumophila **serogroup 1,** which accounted for 98% of L. pneumophila cases The Legionella urinary antigen assay should be reserved for patients with high-severity CAP and those with risk factors for Legionella infection

Question 45

Are serological tests like IgM for Mycoplasma useful?

Answer 45

Rarely useful in the acute setting

Question 46

Whats the role of adunctive corticosteroids in CAP?

Answer 46

adjunctive corticosteroids are **not recommended** for patients with low- and moderate-severity CAP

Question 47

If an oral cephalasporin is used to treat a CAP with allergy to penicillin which one is best?

Answer 47

If an oral cephalosporin is required to treat CAP for a patient with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins, **cefuroxime** is preferred to cefalexin or cefaclor because of its superior antipneumococcal activity.

Question 48

For penicillin susceptible infections - is ceftriaxone better than ben pen?

Answer 48

For penicillin-susceptible infections, ceftriaxone and cefotaxime **do not** have superior activity against H. influenzae and S. pneumoniae compared to penicillins.

Question 49

If a patient is finishing a benpen course - which oral should they be switched to amoxil or augmentin?

Answer 49

Amoxil 1g tds Compared to Aug DF it's is less selective for resistance has fewer adverse effects at the dosage recommended for CAP (1 g, 8-hourly), achieves significantly higher plasma concentrations of amoxicillin (which is needed in case of infection due to S. pneumoniae with a higher minimum inhibitory concentration [MIC] to penicillin).