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50 Cards in this Set

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Asthma affects how many Australians?
More than 2 million.
What is the typical disease pattern of asthma?
- 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.
What can be used for diagnosis of asthma?
- Clinical features only in children < 7-8 years.
- PEFR/spirometry.
- CXR.
- Challenge tests.
- Allergy testing.
When should inhaled steroids be commenced with asthma?
- 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.
Should you titrate up inhaled steroids?
Yes.
If response to inhaled steroids is poor in suspected asthma, what should be done?
- 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.
A post nasal drip cough is commonly misdiagnosed as....
Bronchitis.
What are the clinical features of a post-nasal drip?
- 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.
What is the typical treatment for a post-nasal drip?
- Decongestants (oral, nasal).
- "Wash outs" - steam, nasal saline.
- Adjunctive treatments e.g. gargles, cough suppressants.
What is the differential diagnosis of an acute cough lasting less than 3 weeks?
- Common cold.
- Allergic rhinitis.
- Acute bacterial sinusitis.
- Post nasal drip.
- Asthma.
- Exacerbations of COPD.
- Pertussis, mycoplasma, etc.
What is the differential diagnosis of a chronic cough (longer than 3 weeks)?
- Any cause of acute cough.
- Gastroesophageal reflux.
- ACE inhibitor.
- Lung cancer.
- TB.
- Sarcoidosis.
- Mediastinal lesion.
- Goitre.
- Pulmonary oedema.
What do you look for on spirometry to diagnose COPD?
<70% post-bronchodilator FEV1/FVC.
Tiotropium may improve COPD lung function by up to ___%.
Tiotropium may improve COPD lung function by up to 12%.
How do you achieve best lung function?
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.
What type of asthma are sodium cromoglycate and nedocromil most effective against?
Effective in asthma induced cough/seasonal allergic asthma and exercise induced asthma.

Try a 4 week trial.
How do you optimise for best lung function?
- Prevent respiratory infections.
- Check on other medications (aspirin, beta blocker).
- Check inhalter technique.
- GORD.
- Reduce irritants/triggers.
- In adults, check for occupational exposure.
What do you assess to determine if you've achieved best lung function in asthma?
- 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.
What do you look for to identify high-risk asthma patients?
- 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)
For an acute exacerbation of COPD, what would you do in terms of management?
- 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).
If pneumonia is suspected in COPD, what should you do?
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.
In what patients should inhaled corticosteroids be used in acute exacerbations of COPD?
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.
What other aspects of COPD exacerbation management are there other than pharmacological?
- 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.
What should a patient keep at home for self-management if they are prone to COPD exacerbations?
Patients at risk of COPD exacerbations should keep a course of antibiotic and corticosteroid tablets
at home for use as part of self-management.
What strategies can you use to assist with smoking cessation?
- 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.
What is the single most important intervention to prevent or slow progression of COPD?
Quit smoking.
How many COPD exacerbations per year is associated with more rapid lung function decline?
2 or more exacerbations.
At what percentage range would a patient's FEV1 have to be to have moderate COPD?
40-60%.
For COPD exacerbation, what features would indicate need for hospital admission?
- Presence of cyanosis.
- Peripheral oedema.
- Acute confusion.
- Severe tachypnoea.
- Impaired physical functioning and inability to cope at home.
What anticholinergic bronchodilators may be used for COPD?
- Ipratropium.
- Tiotropium.
What is symbicort?
Combination of budesonide and eformoterol.
What is seretide?
Combination of salmeterol and fluticasone.
What inhaled corticosteroids could be used for COPD?
- Beclomethasone.
- Budesonide.
- Fluticasone.
Why shouldn't fixed-dose combination products be used when trying to achieve optimum control with asthma?
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.
What is the gold standard test for diagnosing asthma?
Spirometry.
What use would peak flow meters have in asthma management?
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.
What are zafirlukast and montelukast?
Leukotriene receptor antagonists.
Spirometry for asthma is useful in general practice because it can....
- 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.
Describe the six step asthma management plan.
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.
What are the four grades of severity of asthma?
- Very mild (intermittent/episodic).
- Mild persistent.
- Moderate persistent.
- Severe persistent.
What does an asthma action plan outline?
An action plan outlines how to:
- Recognise symptoms of
asthma deterioration.
- Modify treatment accordingly.
- Access prompt medical
assistance.
What are the advantages of using a spacer?
- 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.
What are the advantages of using a dry power inhaler?
- 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.
How frequently should plastic spacers be washed?
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.
You should consider pharmacotherapy for quitting smoking with patients who smoke more than ___ cigarettes a day.
You should consider pharmacotherapy for quitting smoking with patients who smoke more than 10 cigarettes a day.
When should an acute exacerbation of COPD be referred for hospital admission?
- Increased intensity of symptoms.
- New or worsening cyanosis or
peripheral oedema.
- Inability to perform daily activities.
- Altered mental state.
- Exacerbation of comorbidities.
What antibiotics could you prescribe if the COPD exacerbation is refractory to amoxycillin or doxycycline.
Use macrolide antibiotics (e.g. erythromycin, roxithromycin), cephalosporins or
amoxycillin plus clavulanic acid if there is no response
to amoxycillin or doxycycline.
How long should you prescribe antibiotics for an acute exacerbation of COPD?
5-10 days.
How long should you prescribe oral corticosteroids for an acute exacerbation of COPD?
7-14 days.
Which microorganism must you exclude before prescribing macrolides as a 2nd-line antibiotic for a COPD exacerbation?
Macrolides are less likely
to inhibit Haemophilus influenzae so early relapse is
more likely: use only if this pathogen has been
excluded.
What do you need to do for follow-up of an acute exacerbation of COPD?
- 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.