A 27-year-old woman is reviewed in the asthma clinic. She currently uses salbutamol inhaler 100mcg prn combined with beclometasone dipropionate inhaler 400mcg bd. Despite this she is having frequent exacerbations of her asthma and recently required a course of prednisolone.
What is the most appropriate next step in management?
Correct Answer C: The management of stable asthma is now well established with a step-wise approach:
*Beclometasone dipropionate or equivalent
Leukotriene receptor antagonists:
Fluticasone is more lipophilic and has a longer duration of action than beclometasone.
Hydrofluoroalkane is now replacing chlorofluorocarbon as the propellant of choice. Only half the usually dose is needed with hydrofluoroalkane due to the smaller size of the particles.
Long acting B2-agonists acts as bronchodilators but also inhibit mediator release from mast cells. Recent metaanalysis showed adding salmeterol improved symptoms compared to doubling the inhaled steroid dose.
Which one of the following would cause a rise in the carbon monoxide transfer factor (TLCO)?
Correct Answer C: Where alveolar haemorrhage occurs the TLCO tends to increase due to the enhanced uptake of carbon monoxide by intra-alveolar haemoglobin.
Transfer factor:
The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or that corrected for lung volume (transfer coefficient, KCO).
KCO also tends to increase with age. Some conditions may cause an increased KCO with a normal or reduced TLCO:
Which one of the following is responsible for farmer's lung?
Correct Answer B: Saccharopolyspora rectivirgula causes farmer's lung, a type of Extrinsic Allergic Alveolitis (EAA).
Extrinsic allergic alveolitis: Extrinsic allergic alveolitis (EAA, also known as hypersensitivity pneumonitis) is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles. It is thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
Examples:
Presentation:
Investigation:
*here the terminology is slightly confusing as thermophilic actinomycetes is an umbrella term covering strains such as Micropolyspora faeni
Which of the following factors is least useful in assessing patients with a poor prognosis in community-acquired pneumonia?
Correct Answer C: The C-reactive protein is the least useful of the above in predicting mortality in patients with community-acquired pneumonia. The rest of the answers are part of the CURB-65 criteria.
Pneumonia: prognostic factors:
CURB-65 criteria of severe pneumonia:
Patients with 3 or more (out of 5) of the above criteria are regarded as having a severe pneumonia .
Other factors associated with a poor prognosis include:
A 24-year-old female presents with episodic wheezing and shortness of breath for the past 4 months. She has smoked for the past 8 years and has a history of eczema. Examination of her chest is unremarkable. Spirometry is arranged and is reported as normal.
What is the most appropriate management of her symptoms?
Correct Answer E: The new British Thoracic Society guidelines take a more practical approach to diagnosing asthma. If a patient has typical symptoms of asthma a trial of treatment is recommended. Normal spirometry when the patient is well does not exclude a diagnosis of asthma. The smoking history is unlikely to be relevant at her age.
What is not necessarily clear is whether all patients should have spirometry prior to starting treatment - how do you interpret the guidelines?
Asthma: diagnosis in adults:
The 2008 British Thoracic Society guidelinesmarked a subtle change in the approach to diagnosing asthma. This approach is supported in the updated 2011 guidelines. It suggests dividing patients into a high, intermediate and low probability of having asthma based on the presence or absence of typical symptoms. A list can be found in the external link but include typical symptoms such as wheeze, nocturnal cough etc.
Example of features used to assess asthma (not complete):
Management is based on this assessment:
For patients with an intermediate probability of asthma further investigations are suggested. The guidelines state that spirometry is the preferred initial test:
Recent studies have shown the limited value of other 'objective' tests. It is now recognised that in patients with normal or near-normal pre-treatment lung function there is little room for measurable improvement in FEV1 or peak flow.
A > 400 ml improvement in FEV1 is considered significant:
It is now advised to interpret peak flow variability with caution due to the poor sensitivity of the test:
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