Cough And Breathlessness

Front 1

Asthma affects how many Australians?

Back 1

More than 2 million.

Front 2

What is the typical disease pattern of asthma?

Back 2

- Often starts in early childhood, grow out of it in adolsescent.
- 50% recurrence in later adolescence/early adult life.
- May begin de novo in mid/late adulthood.

Front 3

What can be used for diagnosis of asthma?

Back 3

- Clinical features only in children < 7-8 years.
- PEFR/spirometry.
- CXR.
- Challenge tests.
- Allergy testing.

Front 4

When should inhaled steroids be commenced with asthma?

Back 4

- Benefit even in mild asthma if:
- Exacerbation in past 2 years.
- Use of ventolin required > 3/week.
- Symptoms >3/week, or nocturnal or morning symptoms.

Front 5

Should you titrate up inhaled steroids?

Back 5

Yes.

Front 6

If response to inhaled steroids is poor in suspected asthma, what should be done?

Back 6

- Check medication delivery/adherence.
- Check for other causes (GORD, cardiac, lung lesion, infection). You need to figure out if it's asthma plus a second disease, or not asthma at all!
- Check for triggers.
- Consider severe asthma that needs more than inhaled steroids.

Front 7

A post nasal drip cough is commonly misdiagnosed as....

Back 7

Bronchitis.

Front 8

What are the clinical features of a post-nasal drip?

Back 8

- Moist/dry cough. Difficult to clear the mucus.
- Cough worse in the evening, lying down and arising.
- Often associated with nasal symptoms, sore throat.
- Upon examination, there may be adherence mucus, lymph hyperplasia ('cobblestoning' appearance), or diffuse mild redness of pharynx.

Front 9

What is the typical treatment for a post-nasal drip?

Back 9

- Decongestants (oral, nasal).
- "Wash outs" - steam, nasal saline.
- Adjunctive treatments e.g. gargles, cough suppressants.

Front 10

What is the differential diagnosis of an acute cough lasting less than 3 weeks?

Back 10

- Common cold.
- Allergic rhinitis.
- Acute bacterial sinusitis.
- Post nasal drip.
- Asthma.
- Exacerbations of COPD.
- Pertussis, mycoplasma, etc.

Front 11

What is the differential diagnosis of a chronic cough (longer than 3 weeks)?

Back 11

- Any cause of acute cough.
- Gastroesophageal reflux.
- ACE inhibitor.
- Lung cancer.
- TB.
- Sarcoidosis.
- Mediastinal lesion.
- Goitre.
- Pulmonary oedema.

Front 12

What do you look for on spirometry to diagnose COPD?

Back 12

<70% post-bronchodilator FEV1/FVC.

Front 13

Tiotropium may improve COPD lung function by up to ___%.

Back 13

Tiotropium may improve COPD lung function by up to 12%.

Front 14

How do you achieve best lung function?

Back 14

Preventors:
- Mast cell stabiliser - Sodium cromoglycate or nedocromil.
- LTR-A - motelukast, zafirlukast.
- Inhaled corticosteroids (budesonide, fluticasone).

Symptom controllers:
- Long acting beta agonists - salmeterol, eformoterol.

Relievers:
- Salbutamol.
- Terbutaline.
- Ipratropium.

Combination drugs:
- Seretide.
- Symbicort.

Front 15

What type of asthma are sodium cromoglycate and nedocromil most effective against?

Back 15

Effective in asthma induced cough/seasonal allergic asthma and exercise induced asthma.

Try a 4 week trial.

Front 16

How do you optimise for best lung function?

Back 16

- Prevent respiratory infections.
- Check on other medications (aspirin, beta blocker).
- Check inhalter technique.
- GORD.
- Reduce irritants/triggers.
- In adults, check for occupational exposure.

Front 17

What do you assess to determine if you've achieved best lung function in asthma?

Back 17

- Patient has minimal symptoms.
- Using the reliever less than 3 times a week.
- Minimal nocturnal symptoms.
- Normal lung function or close to personal best.
- Compliance and technique testing.
- Optimise and back-titrate the preventative medication over several months.

Front 18

What do you look for to identify high-risk asthma patients?

Back 18

- Frequent ED visits and/or any ICU admissions.
- Need for continuous oral steroids.
- Failure to perceive asthma symptoms.
- Denial.
- Poor adherence/poor control - especially in young adults and teenagers.
- Immediate hypersensitivity reactions to foods.
- >25% diurnal variation in PEF (adults)

Front 19

For an acute exacerbation of COPD, what would you do in terms of management?

Back 19

- Increase use of short-acting bronchodilator.
- Consider oral prednisolone for 7-14 days.
- Consider antibiotic therapy if increased sputum purulence (amoxycillin or doxycyline for 5 days).

Front 20

If pneumonia is suspected in COPD, what should you do?

Back 20

Investigate and treat as for community-acquired pneumonia:
- History and examination.
- Chest x-ray.
- Measurement of arterial blood oxygen saturation.
- Investigate for the causal pathogen.
- Pneumonia Severity Index class.

Front 21

In what patients should inhaled corticosteroids be used in acute exacerbations of COPD?

Back 21

Patients who have documented evidence of responsiveness to inhaled corticosteroids, or who have moderate or severe COPD (FEV1 ≤ 50% predicted) and have 2 or more exacerbations requiring treatment with antibiotics or oral corticosteroids in a 12-month period.

Front 22

What other aspects of COPD exacerbation management are there other than pharmacological?

Back 22

- Advise/assist with smoking cessation.
- Oxygen (if severe).
- Reassess lung function (via spirometry).
- Review/optimise drug therapy.
- Recommend respiratory rehabilitation.
- Ensure currency of influenza and/or pneumococcal vaccination.
- Recommend exercise.
- Check inhaler technique.
- Prepare an action plan.
- Assess compliance.
- Psychosocial support.

Front 23

What should a patient keep at home for self-management if they are prone to COPD exacerbations?

Back 23

Patients at risk of COPD exacerbations should keep a course of antibiotic and corticosteroid tablets
at home for use as part of self-management.

Front 24

What strategies can you use to assist with smoking cessation?

Back 24

- Counselling and encouragement.
- Refer to Quitline.
- Support, followup, review.
- Discuss benefits and risks.
- Assess readiness to change.
- Written material and education.
- Behavioural therapy.
- Ask, advice, assess, assist, arrange.
- Nicotine replacement therapy.
- Bupropion.

Front 25

What is the single most important intervention to prevent or slow progression of COPD?

Back 25

Quit smoking.

Front 26

How many COPD exacerbations per year is associated with more rapid lung function decline?

Back 26

2 or more exacerbations.

Front 27

At what percentage range would a patient's FEV1 have to be to have moderate COPD?

Back 27

40-60%.

Front 28

For COPD exacerbation, what features would indicate need for hospital admission?

Back 28

- Presence of cyanosis.
- Peripheral oedema.
- Acute confusion.
- Severe tachypnoea.
- Impaired physical functioning and inability to cope at home.

Front 29

What anticholinergic bronchodilators may be used for COPD?

Back 29

- Ipratropium.
- Tiotropium.

Front 30

What is symbicort?

Back 30

Combination of budesonide and eformoterol.

Front 31

What is seretide?

Back 31

Combination of salmeterol and fluticasone.

Front 32

What inhaled corticosteroids could be used for COPD?

Back 32

- Beclomethasone.
- Budesonide.
- Fluticasone.

Front 33

Why shouldn't fixed-dose combination products be used when trying to achieve optimum control with asthma?

Back 33

Reserve the use of fixed-dose combination products (long-acting beta2-agonist plus an
inhaled corticosteroid) for when control has been achieved with the individual components because reducing to a minimum effective dose of inhaled corticosteroids with such combination products may be complex.

Front 34

What is the gold standard test for diagnosing asthma?

Back 34

Spirometry.

Front 35

What use would peak flow meters have in asthma management?

Back 35

Peak flow meters are not a substitute for spirometry for routine assessment of asthma
by the practitioner. They are best used as an aid to patients self-managing their asthma by serially recording peak expiratory flow rates and comparing these to their
pre-determined best peak flow.

Front 36

What are zafirlukast and montelukast?

Back 36

Leukotriene receptor antagonists.

Front 37

Spirometry for asthma is useful in general practice because it can....

Back 37

- Confirm the diagnosis.
- Measure the degree of obstruction and the extent of subsequent bronchodilation.
- Compare those measurements with predicted normal, using reliable height/age/sex tables.
• Visually demonstrate to the patient the presence and severity of his asthma.
• Review his bronchodilator technique.

Front 38

Describe the six step asthma management plan.

Back 38

Step 1. Asess severity.
Step 2. Achieve best lung function.
Step 3. Maintain best lung function by avoiding trigger factors.
Step 4. Maintain best lung function with optimal medication.
Step 5. Develop an individualised, written action plan.
Step 6. Educate and review regularly.

Front 39

What are the four grades of severity of asthma?

Back 39

- Very mild (intermittent/episodic).
- Mild persistent.
- Moderate persistent.
- Severe persistent.

Front 40

What does an asthma action plan outline?

Back 40

An action plan outlines how to:
- Recognise symptoms of
asthma deterioration.
- Modify treatment accordingly.
- Access prompt medical
assistance.

Front 41

What are the advantages of using a spacer?

Back 41

- Increase the proportion of an inhaled dose deposited
in the airways.
- Reduce oropharyngeal drug deposition with MDIs,
decreasing local unwanted effects such as oral candidiasis with corticosteroids (particularly at high doses).
- Circumvent inspiratory coordination problems that
patients (particularly children and the elderly) may
have when actuating MDIs.

Front 42

What are the advantages of using a dry power inhaler?

Back 42

- Increase the proportion of an inhaled dose deposited
in the airways relative to an MDI.
- Overcome inspiratory coordination problems.
- Are more portable than a spacer.

Front 43

How frequently should plastic spacers be washed?

Back 43

Plastic spacers should be washed at least monthly with ordinary household detergent and allowed to dry in air (i.e. no rinsing, no wiping).
This diminishes the build-up of electrostatic charges on the spacer walls that attract aerosol particles and reduce the dose delivered.

Front 44

You should consider pharmacotherapy for quitting smoking with patients who smoke more than ___ cigarettes a day.

Back 44

You should consider pharmacotherapy for quitting smoking with patients who smoke more than 10 cigarettes a day.

Front 45

When should an acute exacerbation of COPD be referred for hospital admission?

Back 45

- Increased intensity of symptoms.
- New or worsening cyanosis or
peripheral oedema.
- Inability to perform daily activities.
- Altered mental state.
- Exacerbation of comorbidities.

Front 46

What antibiotics could you prescribe if the COPD exacerbation is refractory to amoxycillin or doxycycline.

Back 46

Use macrolide antibiotics (e.g. erythromycin, roxithromycin), cephalosporins or
amoxycillin plus clavulanic acid if there is no response
to amoxycillin or doxycycline.

Front 47

How long should you prescribe antibiotics for an acute exacerbation of COPD?

Back 47

5-10 days.

Front 48

How long should you prescribe oral corticosteroids for an acute exacerbation of COPD?

Back 48

7-14 days.

Front 49

Which microorganism must you exclude before prescribing macrolides as a 2nd-line antibiotic for a COPD exacerbation?

Back 49

Macrolides are less likely
to inhibit Haemophilus influenzae so early relapse is
more likely: use only if this pathogen has been
excluded.

Front 50

What do you need to do for follow-up of an acute exacerbation of COPD?

Back 50

- Asking about smoking and offering cessation advice.
- Assessing lung function and performing spirometry.
- Reviewing and optimising drug treatments.
- Checking compliance and inhaler technique.
- Ensure up to date with flu and pneumococcal vaccination.