Respirology

Question 1

Emphysema etiology

Answer 1

Destruction of alveoli

Question 2

Chronic bronchitis etiology

Answer 2

Inflammation of the bronchioles

Question 3

Chronic bronchitis diagnosis

Answer 3

Clinical diagnosis

Chronic cough + sputum >3 months/year x 2 years

Question 4

COPD risk factors

Answer 4

Smoke exposure/inhaled chemicals

Alpha 1 antitrypsin deficiency

Severe childhood respiratory disease/asthma

Question 5

COPD epidemiology

Answer 5

4.4% Canadians

Female more common than male

4th leading cause of death

Question 6

COPD screening

Answer 6

Spirometry if

1. Smoker/ex smoker, >40 y/o and sx (persistent cough, phlegm, wheeze, recurrent URTI, exertional SOB)
2. > 40 y/o with resp symptoms AND environmental exposure/frequent resp infections/family history of COPD

Question 7

COPD diagnosis

Answer 7

1. Spirometry
   Fixed post bronchodilator FEV1/FVC < 0.7
2. Alpha1 antritrypsin serum level if <65 y/o or smoking history of <20 pack years

Question 8

COPD classifications

Answer 8

COPD Assessment Tool (CAT) or modified Medical Research Council (mMRC)

Mild - SOB with hurried walk, recurrent chest infections, FEV1>80%

Moderate - SOB requiring rest ~100m/few mins, limits in daily activities, exacerbations requiring corticosteroids +/- abx, FEV1 50-79%

Severe - Breathless after dressing, resp/cardiac failure, FEV1 30-49%

Question 9

Routine management/prevention of AECOPD

Answer 9

Smoking cessation - single most effective intervention

Vaccines - annual influenza + pneumococcal (+booster @5 years)

Puffers - review technique + action plan

Activity - negative repercussions of inactivity (ESOB is not life threatening!!), stay indoors when air quality is poor

Question 10

Which pharmocological agent slows progression of COPD

Answer 10

None

Question 11

Pharmacotherapy evaluation follow up time frame

Answer 11

6 months or 12 months if it includes an ICS

Question 12

Pharmacotherapy approach COPD

Answer 12

Mild

1. Short acting bronchodilator (SABD) prn only
2. LAMA (preferred) or LABA

Moderate/Severe and low risk of AECOPD 0-1 moderate AECOPD in last 12 months

1. LAMA (preferred) or LABA
2. LAMA/LABA
3. LAMA/LABA/ICS

Moderate/Severe and high risk of AECOPD 2+ moderate AECOPD or 1+ severe AECOPD

1. LAMA/LABA (preferred) or ICS/LABA (consider if blood eosinophil 300 uL+ or concomitant asthma)
2. LAMA/LABA/ICS
3. Oral therapies (macrolide, Raflumilast, N-acetylcysteine)

Question 13

Examples of short acting bronchodilators

Answer 13

Short acting muscarinic antagonists
Ipratropium (Atrovent) 2 puffs QID

Short acting beta 2 agonists
Salbutamol (Ventolin) 1-2 puffs QID
Terbutaline (Bricanyl) 1 puff QID

SAMA/SABA
Ipratropium + salbutamol (Combivent) 1 puff QID

Question 14

Examples of LAMAs

Answer 14

Long acting antimuscarinic antagonist
Tiotropium (Spiriva) 1 cap/2 puffs once daily
Aclidinium (Tudorza) 1 puff BID
Glycopyrronium (Seebri) 1 cap once daily
Umeclidinium (Incruse) 1 puff once daily

Question 15

Examples of LABAs

Answer 15

Long acting beta2 agonists 
Salmeterol (Serevent) 1 puff BID 
Formoterol (Oxeze) 1 cap/6-12 ug BID 
Indacaterol (Onbrez) 1 cap inahled once daily  
Olodaterol 2 puffs once daily

Question 16

Examples of LAMA/LABAs

Answer 16

Umeclidinium + vilanterol (Anoro) 1 puff once daily
Glycopyrronium + Indacaterol (Ultibro) 1 puff once daily
Tiotropium + Olodaterol (Inspiolto) 2 puffs once daily
Aclidinium + Formoterol (Duaklir) 1 puff BID

Question 17

Examples of LABA/ICS

Answer 17

Formoterol + budesonide (Symbicort) 12/400 mcg BID
Salmeterol + fluticasone (Advair) 50/250 mcg BID
Vilanterol + fluticasone (Breo) 1 puff once daily

Question 18

Role of ICS in COPD

Answer 18

No monotherapy!

Blood eosinophil 300 uL+ predicts response to ICS (unlikely to respond if 0-100)

Note increase risk of pneumonia with ICS use but no change in mortality

Question 19

AECOPD definition

Answer 19

Sustained >48h worsening of symptoms (dyspnea, cough, sputum volume/purulence)

Question 20

Classification of AECOPD severity

Answer 20

Mild - change in sx but no abx or steroids needed

Moderate - abx +/- steroids

Severe - hospitalization/ER visit

Question 21

AECOPD causes

Answer 21

Infection (50%)
H. influenza, S. pneumonia, M. catarrhalis

CHF

Irritants

PE

MI

Anemia

Question 22

AECOPD management

Answer 22

1. Ventolin + LAAC (Spiriva)
2. For moderate to severe give 30-40 mg prednisone/day x 5 days with no taper. Usually must persist >48h before starting oral steroids or abx
3. Increased purulence (or moderate to severe symptoms) - antibiotics
   If point of care CRP <40 then patient likely does not need abx

Simple - 5 days (FEV1>50%, mild-mod, 0-3 exacerbations/year, no cardiac disease)
First line
a) Amoxicillin 500 mg TID
b) Doxycycline 100 mg BID x 1 day then 100 mg once daily
c) Tetracycline 250-500 mg QID
d) TMP/SMX 2 tabs BID or 1 DS tab BID
Second line
a) Clarithromycin 500 mg BID OR 1000 mg extended release once daily
b) Azithromycin 500 mg x 1 then 250 mg once daily x 4 days OR 500 mg once daily x 3 days
c) Cefuroxime 500 mg BID
d) Cefprozil 500 mg BID

Complicated/high risk 7-10 days (FEV1 <50%, 4+ exacerbations/year, cardiac disease)
First line
a) Amoxicillin/Clavulanate 500 mg TID or 875 mg BID
Second line
a) Levofloxacin 500 mg once daily x 7 days or 750 mg once daily x 5 days
b) Moxifloxacin 400 mg once daily

At risk of Pseudomonas (FEV1<35% predicted, chronic steroids, constant purulent sputum)
1. Ciprofloxacin 500-750 mg BID

Question 23

Indication for pulmonary rehabilitation in COPD

Answer 23

Remains dyspneic despite dual therapy LAMA/LABA

Question 24

What is the target oxygenation level in COPD

Answer 24

Goal sats >90%

Survival advantage if arterial oxygen <55 mm Hg

Question 25

When to refer COPD cases

Answer 25

``` Diagnosis uncertain Symptoms severe/unproportionate to spirometry Failure to respond to therapy Accelerated decrease of lung function Onset 0-40 y/o Complex co-morbidities Assessment for pulmonary rehabilitation Home oxygen Surgical therapy ```

Question 26

Indications for continuous long-term oxygen therapy (LTOT) for patients with chronic lung disease include

Answer 26

●Arterial oxygen tension (PaO2) less than or equal to 55 mmHg (7.32 kPa), or a pulse oxygen saturation (SpO2) less than or equal to 88 percent ●PaO2 less than or equal to 59 mmHg (7.85 kPa), or an SpO2 less than or equal to 89 percent, if there is evidence of cor pulmonale, right heart failure, or erythrocytosis (hematocrit >55 percent) For patients with normal awake oxygenation, oxygen may be prescribed during sleep if any of the following occur during sleep: the PaO2 is 55 mmHg or less the SpO2 is 88 percent or less the PaO2 decreases more than 10 mmHg (1.33 kPa), and/or the SpO2 decreases more than 5 percent with signs or symptoms of nocturnal hypoxemia (eg, impaired cognitive function, morning headaches, restlessness, or insomnia). In this setting, portable oxygen would not be covered. Oxygen may be prescribed during exercise if there is a reduction of PaO2 to 55 mmHg or less or SpO2 to 88 percent or less during exercise. Additionally, oxygen may be warranted during exercise even in those patients who do not significantly desaturate during exercise, if they have dyspnea and ventilatory abnormalities during exercise that suggest supplemental oxygen may permit greater exertion. This is supported by studies that found that hyperoxia increases exercise endurance in a dose-dependent manner, up to an inspired oxygen fraction of 50 percent or a flow rate of 6 L/min. The use of supplemental oxygen in the palliative treatment of dyspnea in non-hypoxemic patients is not well supported by the literature. Pharmacological management is first line for this

Question 27

Asthma triggers

Answer 27

``` Cold air Exercise Viral illness Allergen Irritant Food (sulphites, MSG, cold drinks) Meds (beta blockers, NSAIDs, aspirin) Strong emotion ```

Question 28

Asthma aggravating comorbidities

Answer 28

``` Rhinitis/rhinosinusitis Sleep apnea GERD Obesity Stress/depression/anxiety Psychosocial issues ```

Question 29

Asthma prevention

Answer 29

Primary Conflicting evidence for avoiding early life exposure to pets, unless both parents are atopic then stronger evidence Secondary Avoid tobacco Tertiary Allergens that patients are sensitive to should be identified and systematically removed

Question 30

Diagnosis <6 years old

Answer 30

Patient and family history If refractory to tx exclude other pathology Assess for atopy which predicts persistent asthma Age 1-5 years old Abandon terms such as "reactive airway" "bronchospasm" Require all 3 of the following during 2+ episodes 1. Documentation of airflow obstruction (cough/difficulty breathing/wheeze) - Preferred: documented by physician - Alternative: convincing parental report of wheezing 2. Documentation of reversibility of airflow obstructions - Preferred: physician observed improvement in signs of airflow obstruction to SABA +/- oral corticosteroid Mild symptoms, 4 puffs salbutamol, reassess 30 min Mod symptoms, 4 puffs salbutamol, reassess 60 min (may need 2-3 doses of 4 puffs within 60 min) OR mod symptoms oral steroid (dexamethasone 0.15-0.6 mg/kg max 50 mg) 1 dose, reassess in 3-4 hours - Alternative: convincing parental report of symptomatic response to 3 month trial medium dose ICS with PRN SABA, expect 50% decrease in # off exacerbations (should document daytime/nighttime symptoms, SABA use, exacerbations) 3. No clinical evidence of an alternative diagnosis

Question 31

Diagnosis asthma 6+ years old

Answer 31

- Patient and family history - MUST have spirometry and in its absence, a positive methacholine or exercise challenge test or sufficient peak expiratory flow variability - If refractory to treatment, exclude other pathology - Assess for atopy which predicts persistent asthma - Any signs/symptoms of variable lower airway obstruction + response to therapy suggests asthma diagnosis but definitive diagnosis needed DO NOT order full pulmonary function testing or CXR to confirm asthma unless questioning a diagnosis other than asthma For accuracy, discontinue ICS+/- LABA 24 hr prior to spirometry ``` Spirometry (preferred) - Children >6 Decreased FEV1/FVC <0.8-0.9 Increased FEV1 12% with bronchodilator - Adults Decreased FEV1/FVC <0.75-0.8 Increased FEV1 12% with bronchodilator ``` ``` PEF (alternative) - Children >6 Increased min 20% with bronchodilator - Adults Increased 60L/min (min 20%) with bronchodilator Diurnal variation >8% if measured BID ``` Methacholine PC20 <4 mg/mL (4-16 borderline, >16 negative) Exercise Decreased FEV1 minimum 10% post exercise

Question 32

Asthma control

Answer 32

``` Daytime symptoms <4 days/week Need for Ventolin < 4 dose/week Night-time symptoms <1 night/week FEV 1 or PEF 90%+ personal best PEF diurnal variation <15% Sputum eosinophils (mod to severe asthma) <3% Physical activity normal Exacerbation mild, infrequent Absence from work/school secondary to asthma none ```

Question 33

Asthma nonpharmacologic management

Answer 33

Encourage aerobic exercise Strongly encourage smoking cessation Consider avoiding NSAIDs (10-20% are sensitive to NSAIDs/aspirin and non-cardioselective BB) Avoiding all allergens and environmental triggers is unrealistic If risk of anaphylaxis, ensure auto-renewable prescription of epi-pen Consider annual influenza vaccination

Question 34

SABA drugs, doses, routes

Answer 34

Short acting beta 2 agonist (SABA) - Ventolin (Salbutamol) 100 mcg 2 puffs q4-6 hours - Bricanyl Turbuhaler (Terbutaline) 2.5 mg 1-2 puffs q6h

Question 35

Inhaled corticosteroid adverse effects

Answer 35

Delay growth velocity Oral thrush Dysphonia

Question 36

Risk of LABA monotherapy

Answer 36

Associated with increase asthma morbidity

Question 37

Role of SAAC in asthma

Answer 37

less effective than SABA

Question 38

ICS drugs, doses, routes

Answer 38

Inhaled corticosteroid - Flovent (fluticasone) 50, 125, 250 mcg 1 puff BID - Pulmicort (Budesonide) 100, 200, 400 mcg 1 puff BID

Question 39

ICS + LABA drugs, doses, routes

Answer 39

ICS + long acting beta 2 agonist (LABA) ** NO LABA MONOTHERAPY - Symbicort budesonide/formoterol 100/6, 200/6 2 buffs BID - Advair fluticasone/salmeterol 100/50, 250/50, 500/50 1 puff BID

Question 40

LTRA drugs, doses, routes

Answer 40

Leukotriene receptor antagonists (LTRA) | - Singulair (montelukast) 4 mg granules, 4 mg tablets chewable, 5 mg tablets chewable, 10 mg tablets - 1 tab PO Qpm

Question 41

6-11 years old asthma medication ladder

Answer 41

SABA (Ventolin) prn 1. ICS (Flovent 50 ug BID) 2. Increase ICS dose (Flovent 100 ug BID) 3. ICS + LABA (Advair 100/50 BID) *REFER* or ICS + LTRA (Flovent 125 BID + Singulair) *REFER* 4. Increase ICS + LABA (Advair 250/50 ug BID)

Question 42

12 Years old and older asthma medication ladder

Answer 42

SABA (Ventolin) prn 1. ICS (Flovent 50-125 ug BID) 2. ICS + LABA (Symbicort 100/6 or Advair 100/50 BID) * Symbicort can be used as a controller and reliever in 12+ yo 3. Increase ICS + LABA (Symbicort 200/6 BID or Advair 250/50 BID) *REFER* OR ICS/LABA + LTRA (Advair/Symbicort + SIngulair) *REFER* 4. Increase ICS/LABA +LTRA (high dose Advair or Symbicort + Singulair)

Question 43

When to step up asthma therapy

Answer 43

1. Usually using first line medications if no risk factors for exacerbations AND 0-1 daytime symptoms per month 2. Second line meds if risk factors for exacerbations OR 2-8 daytime symptoms/mo or awakenings at night. Can consider intermittent ICS 3. Usually using 3rd line if daytime symptoms most days or awakening 4+ nights per month. REFER IF MODERATE DOSE ICS IS INSUFFICIENT IN A CHILD 4. Respirology may consider high dose ICS/LABA, LAMAs (in adults), biologic therapy (Anti-IgE, Anti-IL5) or oral prednisone) Consider step down therapy only if exacerbation risk is low and asthma is well-controlled for at least 3 months

Question 44

Classifying severity of asthma exacerbation in <6 y/o

Answer 44

PRAM score SaO2 0- 95%+ 1- 92-94% 2- 0-91% Suprasternal retraction 0- absent 2- present Scalene contraction 0-absent 2- present ``` Air entry 0- normal 1- decreased at the base 2- decreased at the apex/base 3- minimal or absent ``` ``` Wheeze 0- absent 1- expiratory 2- inspiratory 3- audible without stethoscope ``` 0-3 mild 4-7 moderate 8+ severe

Question 45

Indications to transfer asthma case 6+ years old to acute care with O2, SABA, ipratropium + reliever

Answer 45

Severe or life threatening: Posture - Hunched forward, not talking in sentences Decreased consciousness ``` Quantitative findings RR >30 P >120 O2 0-89% Accessory muscle use Silent chest ```

Question 46

Acute asthma exacerbation action plan for 6-11 years old

Answer 46

If on SABA - consider starting regular ICS If on ICS and SABA - Prednisone 1 mg/kg x 3-5 days (max 50 mg) OR dexamethasone 0.15-0.6 mg/kg/d (max 10 mg) If on ICS/LABA and SABA - Prednisone 1 mg/kg x 3-5 days (max 50 mg) OR dexamethasone 0.15-0.6 mg/kg/d (max 10 mg) Notes - Warn parents to seek medical attention if child exposed to varicella - In preschool children, dexamethasone can be given at 0.15-0.3 mg/kg/d as the first dose to subsequent 2-4 day course of prednisone or at 0.6 mg/kg/day as part of a 1-2 day course - CPS recommends prednisone or dexamethasone in children - 6 RCTs prednisone x 5d = dexamethasone 0.3-0.6 mg/kg/day x 1-2 days (less vomiting with dexamethasone)

Question 47

Acute asthma exacerbation action plan for 12+ years old

Answer 47

If on SABA - consider starting regular ICS If on ICS and SABA - increase ICS 4 fold x 7-14 days OR Prednisone 30-50 mg 5+ days If on Symbicort +/- SABA - Increase Symbicort 4 puffs BID x 7-14 days OR Prednisone 30-50 mg x 5+ days If on Advair and SABA or Symbicort - Increase ICS 4 fold x 7-14 days OR Prednisone 30-50 mg 5+ days Notes - Warn parents to seek medical attention if child exposed to varicella - CPS recommends prednisone or dexamethasone in children - 6 RCTs prednisone x 5d = dexamethasone 0.3-0.6 mg/kg/day x 1-2 days (less vomiting with dexamethasone)

Question 48

Asthma criteria for hospital admission

Answer 48

Unable to speak sentences Tachypnea >25/min Tachycardia >110/bradycardia PEF <40% predicted Silent chest Cyanosis Confusion

Question 49

Management of status asthmaticus

Answer 49

Oxygen CXR, ABG, PEF B2 agonists with spacer, anticholinergic therapy, corticosteroids IV salbutamol prn

Question 50

Structured evaluation at scheduled asthma visits

Answer 50

1. Document height and weight of children + adolescents (growth velocity and potential side effects of corticosteroid) 2. Document signs and symptoms of adrenal suppression 3. Review disease control, symptoms, activity level, triggers and comorbidities 4. Review risks for exacerbations (hx exacerbations, hospitalizations, intubations, cormobidities, environmental irritants, FEV1 <60%, very high SABA use ex. >1 canister/month, nonadherence/no action plan) 5. Review medication adherence and action plan (technique, barriers) 6. F/u within 1-3 months of diagnosis + initiating treatment and then at least twice per year or as clinically needed. Serial FEV1 (spirometry) at 3-6 months after initiating tx and q1-2 years once control achieved or as clinically indicated

Question 51

Why can you use same dose of asthma medication regardless of age

Answer 51

auto-scaling

Question 52

When to refer asthma patients

Answer 52

Children 1-5 with 2+ exacerbations needing oral steroid or 8+ symptom days/month despite moderate ICS Children 6-11 who fail control on medium dose ICS Recurrent need of oral steroids or frequent symptoms 8+/month Diagnostic uncertainty Need for environmental allergy testing Suspected occupational-related asthma Considering immunotherapy/biologic therapy