Respirology

Question 1

What are the side effects of inhaled corticosteroids?

Answer 1

1. Oral candidiasis
2. Dysphonia
3. Growth suppression
4. Osteopenia

Question 2

What is the next step after low-dose ICS in asthma if uncontrolled? (1-5yo, 6-11yo, >11yo)

Answer 2

• 1-5yo: increased to medium dose ICS
• 6-11yo: same
• >11yo: add LABA

Question 3

What are admission guidelines for bronchiolitis?

Answer 3

1. Signs of severe respiratory distress (indrawing, RR >70, grunting)
2. Supplemental O2 to keep sats >90%
3. Dehydration or hx of poor fluid intake
4. Cyanosis or hx of apnea
5. Infant at high risk of severe disease (born <35wk, <3mo old, hemodynamically significant cardiac disease, immunodeficiency)
6. Family unable to cope

Question 4

What is the differential diagnosis for wheezing in teenagers?

Answer 4

• Asthma
• Vocal cord dysfunction
• Bronchiolitis obliterans
• Bronchitis
• Pulmonary edema
• Interstitial lung disease
• Tumors & lymphadenopathy

Question 5

What are clues for vocal cord dysfunction (instead of another diagnosis)?

Answer 5

• Subjectively more difficulty on inspiration
• Minimal response to aggressive asthma treatment
• A flattened inspiratory flow-volume loop
• Normal expiratory spirometry, lung volumes, and gas

Question 6

What is the gold standard diagnostic test for vocal cord dysfunction?

Answer 6

Laryngoscopy

Question 7

What is the criteria for diagnosis cystic fibrosis?

Answer 7

One of: 1. Presence of typical features of CF (GI, resp, GU), 2. Hx of CF in a sibling OR 3. +NBS

AND One of: 1. 2 elevated sweat Chl concentrations on different days, 2. two CF mutations, OR 3. an abnormal nasal potential difference

Question 8

What is the most common mutation in CF?

Answer 8

F508del (CFTR protein created but misfolded)

Question 9

How do you interpret a Chloride sweat test?

Answer 9

• >60: positive - need 2nd sweat chloride
• 30-59 - intermediate - if 2 CFTR mutations present, suggests diagnosis
• <30 - negative

Question 10

For a cough, what do these key words indicate? Staccato, never during sleep, barking/brassy, abrupt onset, accompanies eating, throat clearing, night cough, sputum

Answer 10

• Staccato, paroxysmal → pertussis, CF, foreign body, chlamydia or mycoplasma
• All day, never during sleep → habit cough
• Barking, brassy → croup, habit cough, tracheomalacia
• Abrupt onset → FB, PE
• Accompanies eating → aspiration, GERD, TEF
• Throat clearing → post-nasal drip, vocal tic
• Night cough → sinusitis, asthma, GERD
• Sputum → infection, CF, bronchiectasis

Question 11

What factors can give a false negative on a sweat chloride test?

Answer 11

Dilution, malnutrition, edema, insufficient sweat quantity, hyponatremia, CFTR mutation with preserved sweat function

Question 12

What factors should you consider if a patient with asthma is using lots of ventolin?

Answer 12

• Do you have the right diagnosis?
• Are there lots of triggers (e.g. environmental)?
• Poor adherence to controller medication
• Poor technique
• Need more medication?

Question 13

What factors should you consider if a patient with asthma is using lots of ventolin?

Answer 13

• Do you have the right diagnosis?
• Are there lots of triggers (e.g. environmental)?
• Poor adherence to controller medication
• Poor technique
• Need more medication?

Question 14

What are the risk factors for mortality in asthma?

Answer 14

• Previous life-threatening events, admissions to an intensive care unit (ICU), intubation
• Hospitalizations or ED visits for asthma in the last year
• Deterioration while on, or recently after stopping, systemic steroids
• Using >1 canister of salbutamol per month
• Lack of an asthma action plan or poor adherence to treatment
• Comorbidities (e.g., food allergy, obesity)
• Low socioeconomic status, psychosocial concerns

Question 15

What are some factors that can cause the sweat chloride test to be falsely positive?

Answer 15

Eczema, untreated Addison’s disease, ectodermal dysplasia, glycogen storage disorders, untreated hypothyroidism, CAH

Question 16

A 2 year old boy with 2 months of wet cough. He is currently in daycare. There have been no cough free days during this time. 3 months ago he had a witnessed chocking episode on a small toy. Physical examination today is normal. Chest radiograph is normal. The most appropriate step in management:

A) Referral for bronchoscopy

B) Inspiratory/Expiratory chest radiograph

C) Treatment with antibiotics for a persistent bronchitis

D) Re-assurance and watchful waiting

Answer 16

Answer: referral for bronchoscopy

Any history of choking episode / eating nuts + symptoms = bronchoscopy right away!

Question 17

A 2 year old boy with 1 months of cough. He is currently in daycare. He has coughed most days, however has had a few cough free days. Cough started with starting daycare. Past medical and family history are unremarkable. Physical examination today is normal. The most appropriate step in management:

A) Referral for bronchoscopy

B) Sweat Chloride

C) Trial of inhaled corticosteroids

D) Re-assurance and watchful waiting

Answer 17

Answer: D

Key clues: cough free days

Question 18

3 year old boy with chronic congestion and daily wet cough since infancy, PE tubes for recurrent otitis media and a history of prolonged oxygen need at birth (born at term). On examination bilateral bronchovesicular breath sounds. Chest radiograph reveals bilateral areas of atelectasis.

The best test would be:

A) Sweat Test

B) Ciliary Electron Microscopy

C) CT Chest

D) Immunoglobulins

Answer 18

Answer: B

Primary ciliary dyskinesia - Characterized by: chronic bronchitis, recurrent rhinosinusitis, middle ear infections, impaired fertility

Dx: curettage from nasal epithelium or endobronchial brushing

Question 19

An 10 year old girl with asthma is prescribed fluticasone 50 mcg 1 puff twice daily. She has no night time symptoms, has daytime symptoms of cough/wheezing 4 times/week most often while playing hockey. The most appropriate next step:

A) Taking salbutamol before exercise

B) Increasing dose of fluticasone to 125 mcg 1 puff twice daily

C) Adding montelukast

D) Adding a long acting beta agonist

Answer 19

Answer: B

• All should receive SABA PRN
• Low risk of exacerbation, but poor control:
  
  • Add controller therapy (ICS 1st line)
  • If >12yo, can offer PRN Symbicort
• High risk of exacerbation
  
  • Switch to daily ICS + SABA PRN
  • If >12yo, can offer PRN Symbicort Turbuhaler (budesonide/formoterol (ICS/LABA) now approved for alternative to SABA PRN or alternative to regular maintenance controller therapy (e.g. ICS)
• If still uncontrolled:
  
  • 1-5yo + 6-11yo: increase low dose ICS to medium dose ICS
  • ≥12yo: add LABA if already on ICS (ideally in the same inhaler device)
• Still uncontrolled:
  
  • 1-5yo: refer to asthma specialist
  • 6-11yo: add LABA or LTRA (montelukast)
  • ≥12yo: add LTRA
• Still uncontrolled:
  
  • Refer to a specialist, consider adding prednisone (no dose suggested…)

Question 20

A 3 year old boy has been diagnosed with 3 pneumonia in the left lower lobe. A repeat chest radiograph at 6 weeks post treatment reveals a persistent unchanged opacity. The most important test would be:

A) Sweat Chloride

B) CT scan without contrast

C) Flexible bronchoscopy

D) CT scan with contrast

Answer 20

Answer: D

CT contrast will look for congenital lung lesions → contrast is important to help with OR planning (arterial blood supply) if needed