A 68-year-old man is admitted with community-acquired pneumonia and treated with co-amoxiclav and clarithromycin. His CURB-65 score is 2. Blood cultures taken on admission grow Streptococcus pneumoniae sensitive to penicillin. On day 3 of treatment, he remains febrile (38.1°C) with ongoing breathlessness. Repeat chest X-ray shows progression of consolidation in the right lower lobe with a small parapneumonic effusion. CRP is 185 mg/L (was 220 mg/L on admission). What is the most appropriate management?
Q32
A 52-year-old woman presents with sudden onset left-sided pleuritic chest pain and breathlessness. She underwent a total hip replacement 10 days ago. On examination, heart rate 98/min, blood pressure 136/84 mmHg, respiratory rate 20/min, SpO2 96% on room air. There is tenderness and swelling of the left calf. ECG shows sinus rhythm with T wave inversion in leads V1-V3. Wells score is calculated as 7 points. D-dimer is requested. What is the most appropriate next investigation?
Q33
A 61-year-old man with newly diagnosed COPD attends the respiratory clinic. He has moderate airflow obstruction (FEV1 58% predicted) with significant breathlessness (MRC dyspnoea grade 3). He has no history of exacerbations. In addition to smoking cessation advice and initiating bronchodilator therapy, what other intervention has been shown to provide the greatest mortality benefit in COPD?
Q34
A 29-year-old woman presents to the Emergency Department with worsening breathlessness over 1 hour. She has a history of asthma usually well controlled. On examination, she is able to speak in short phrases only. Observations: heart rate 132/min, respiratory rate 30/min, SpO2 90% on high-flow oxygen. Peak flow is 120 L/min (predicted 460 L/min, 26% of predicted). She is treated with back-to-back nebulised salbutamol and ipratropium, IV hydrocortisone, and IV magnesium sulphate 2g. After 1 hour, she remains distressed with minimal improvement. SpO2 is 91% on 15L oxygen, heart rate 128/min, respiratory rate 32/min. What is the most appropriate next step?
Q35
A 76-year-old man is admitted with an exacerbation of COPD. He has severe airflow obstruction (FEV1 32% predicted) and is on home oxygen 2 L/min for 16 hours daily. He is a lifelong smoker, currently smoking 10 cigarettes daily. On admission, he is treated with nebulised bronchodilators, prednisolone 30mg daily, and doxycycline. Arterial blood gas on admission (on 28% Venturi mask) shows: pH 7.35, PaCO2 7.1 kPa, PaO2 8.2 kPa, HCO3- 30 mmol/L. After 24 hours of treatment, repeat blood gas shows: pH 7.36, PaCO2 6.8 kPa, PaO2 8.5 kPa. What should be the target oxygen saturation for this patient?
Q36
A 31-year-old woman presents with a 6-month history of variable wheeze and breathlessness. She works as a hairdresser. Symptoms are worse at work and improve on weekends and holidays. Serial peak flow measurements over 4 weeks show greater than 20% variability between readings at work and at home. What is the most appropriate next step in management?
Q37
A 54-year-old woman is admitted with community-acquired pneumonia. She is treated with co-amoxiclav and clarithromycin. On day 4, she develops worsening breathlessness. Chest X-ray shows a new moderate right-sided pleural effusion. Diagnostic pleural aspiration is performed. Analysis shows: pH 6.95, glucose 1.2 mmol/L, LDH 1850 IU/L, protein 42 g/L. Gram stain shows Gram-positive cocci in chains. What is the most appropriate management?
Q38
A 67-year-old man with COPD (FEV1 38% predicted) is admitted with an infective exacerbation. He is treated with nebulised bronchodilators, prednisolone 30mg daily, and doxycycline. On day 3, he develops increasing drowsiness. Arterial blood gas on 28% oxygen shows: pH 7.28, PaCO2 8.2 kPa, PaO2 7.8 kPa, HCO3- 32 mmol/L, BE +6. What is the most appropriate immediate management?
Q39
A 42-year-old man with known severe asthma is reviewed in the respiratory clinic. Despite treatment with high-dose ICS/LABA (fluticasone 500 micrograms/salmeterol 50 micrograms twice daily), montelukast 10mg daily, and a maintenance and reliever therapy regimen, he continues to have frequent exacerbations requiring oral corticosteroids every 2-3 months. Blood tests show peripheral eosinophil count 520 cells/μL. FeNO is 68 ppb. What is the most appropriate next step in management?
Q40
A 37-year-old woman presents with sudden onset breathlessness and right-sided pleuritic chest pain. She returned from Australia 3 days ago after a 24-hour flight. She takes the combined oral contraceptive pill. On examination, heart rate 102/min, blood pressure 132/78 mmHg, respiratory rate 24/min, SpO2 93% on room air. ECG shows sinus tachycardia. D-dimer is 850 ng/mL (normal <500). Her two-level Wells score for PE is calculated. Which clinical feature is NOT part of the two-level Wells score for pulmonary embolism?
Respiratory Medicine UK Medical PG Practice Questions and MCQs
Question 31: A 68-year-old man is admitted with community-acquired pneumonia and treated with co-amoxiclav and clarithromycin. His CURB-65 score is 2. Blood cultures taken on admission grow Streptococcus pneumoniae sensitive to penicillin. On day 3 of treatment, he remains febrile (38.1°C) with ongoing breathlessness. Repeat chest X-ray shows progression of consolidation in the right lower lobe with a small parapneumonic effusion. CRP is 185 mg/L (was 220 mg/L on admission). What is the most appropriate management?
A. Continue current antibiotics for a further 48 hours and reassess (Correct Answer)
B. Perform diagnostic pleural aspiration
C. Add metronidazole to cover anaerobic infection
D. Change antibiotics to meropenem and vancomycin
E. Arrange CT chest with contrast to assess for empyema
Explanation: ***Continue current antibiotics for a further 48 hours and reassess***
- This patient has a confirmed diagnosis of **Streptococcus pneumoniae** sensitive to penicillin, making the current **co-amoxiclav** regimen appropriate.
- Despite ongoing symptoms, the **CRP is decreasing** (220 to 185 mg/L), which indicates a **slow but positive response** to treatment, and clinical improvement often lags behind biochemical markers.
*Perform diagnostic pleural aspiration*
- While a **small parapneumonic effusion** is noted, aspiration is generally reserved for **larger effusions** (e.g., >10mm on lateral decubitus film) or if there is clear clinical deterioration.
- Given the improving CRP, there's no immediate indication for an invasive procedure, as it might resolve with continued appropriate antibiotic therapy.
*Add metronidazole to cover anaerobic infection*
- The blood culture has specifically grown **Streptococcus pneumoniae**, an aerobic organism, and there is no clinical evidence to suggest an **anaerobic infection**.
- **Metronidazole** is typically added for suspected **aspiration pneumonia** or lung abscess, which are not suggested by the current findings.
*Change antibiotics to meropenem and vancomycin*
- Escalating to **broad-spectrum antibiotics** like **meropenem** and **vancomycin** is inappropriate when a **specific pathogen** with known antibiotic sensitivities has been identified.
- This approach promotes **antibiotic resistance** and is only indicated in cases of severe treatment failure or suspicion of highly resistant organisms.
*Arrange CT chest with contrast to assess for empyema*
- A **CT chest** is usually considered if there is a **lack of clinical improvement** after several days (e.g., 5-7 days) of appropriate antibiotic therapy, or if complications are strongly suspected.
- The patient's **CRP is trending downwards**, and radiological progression on an X-ray can lag behind clinical recovery, so a CT is not immediately warranted after only 3 days.
Question 32: A 52-year-old woman presents with sudden onset left-sided pleuritic chest pain and breathlessness. She underwent a total hip replacement 10 days ago. On examination, heart rate 98/min, blood pressure 136/84 mmHg, respiratory rate 20/min, SpO2 96% on room air. There is tenderness and swelling of the left calf. ECG shows sinus rhythm with T wave inversion in leads V1-V3. Wells score is calculated as 7 points. D-dimer is requested. What is the most appropriate next investigation?
A. Await D-dimer result before further imaging
B. Ventilation-perfusion (V/Q) scan
C. CT pulmonary angiogram (Correct Answer)
D. Lower limb Doppler ultrasound
E. Echocardiography
Explanation: ***CT pulmonary angiogram*** - For patients with a **Wells score >4** (PE likely), the gold standard and most appropriate next step is a **CT pulmonary angiogram (CTPA)**. - Clinical features such as **recent major surgery**, pleuritic pain, and **calf tenderness** indicate a high pre-test probability where imaging is required regardless of blood tests. *Await D-dimer result before further imaging* - **D-dimer** has a high negative predictive value but lacks specificity; it should only be used to rule out PE in patients with a **low Wells score (≤4)**. - In high-probability cases, a negative D-dimer is insufficient to exclude a PE, making the test **unnecessary and delaying definitive diagnosis**. *Ventilation-perfusion (V/Q) scan* - **V/Q scanning** is generally reserved as a second-line imaging modality when **CTPA is contraindicated**, such as in patients with severe **renal impairment** or contrast allergy. - While useful, it is less readily available in an emergency setting compared to CTPA and often results in **indeterminate findings**. *Lower limb Doppler ultrasound* - While this test can confirm a **Deep Vein Thrombosis (DVT)**, a negative result does not rule out a **Pulmonary Embolism** that has already embolized from the leg. - Since the patient is presenting with acute **respiratory symptoms**, the primary focus must be direct visualization of the pulmonary vasculature via **CTPA**. *Echocardiography* - **Echocardiography** is primarily used to assess **right ventricular strain** in hemodynamically unstable patients to determine the severity of a PE. - It is not a definitive diagnostic tool for a stable patient with a **Wells score of 7**, where vascular imaging is more sensitive.
Question 33: A 61-year-old man with newly diagnosed COPD attends the respiratory clinic. He has moderate airflow obstruction (FEV1 58% predicted) with significant breathlessness (MRC dyspnoea grade 3). He has no history of exacerbations. In addition to smoking cessation advice and initiating bronchodilator therapy, what other intervention has been shown to provide the greatest mortality benefit in COPD?
A. Pulmonary rehabilitation
B. Annual influenza vaccination (Correct Answer)
C. Inhaled corticosteroids
D. Long-term oxygen therapy
E. Prophylactic azithromycin
Explanation: ***Annual influenza vaccination***
- In COPD patients, **influenza vaccination** has been shown to significantly reduce the risk of exacerbations, hospitalizations, and **all-cause mortality**.
- It is a highly cost-effective intervention and is recommended for all COPD patients regardless of their **FEV1** or symptomatic status.
*Pulmonary rehabilitation*
- While it dramatically improves **exercise capacity**, symptoms, and **quality of life**, it has not been definitively proven to reduce long-term mortality.
- It is primarily indicated for patients with a **breathlessness grade of MRC 3** or above to improve functional status.
*Inhaled corticosteroids*
- These agents are effective at reducing the **frequency of exacerbations** in patients with severe airflow obstruction or frequent flares but do not improve **survival rates**.
- Chronic use is associated with an increased risk of **pneumonia** and should be used judiciously in COPD.
*Long-term oxygen therapy*
- **Long-term oxygen therapy (LTOT)** only provides a survival benefit in patients with **chronic severe hypoxaemia** (PaO2 <7.3 kPa), which is not indicated by this patient's FEV1 alone.
- For patients who do not meet specific **hypoxaemic criteria**, LTOT does not offer a mortality benefit and can be cumbersome.
*Prophylactic azithromycin*
- This intervention is used to reduce the **frequency of exacerbations** in select patients who continue to flare despite optimal inhaler therapy.
- There is no evidence that prophylactic antibiotics provide a **mortality benefit**, and they carry risks of **antibiotic resistance** and hearing loss.
Question 34: A 29-year-old woman presents to the Emergency Department with worsening breathlessness over 1 hour. She has a history of asthma usually well controlled. On examination, she is able to speak in short phrases only. Observations: heart rate 132/min, respiratory rate 30/min, SpO2 90% on high-flow oxygen. Peak flow is 120 L/min (predicted 460 L/min, 26% of predicted). She is treated with back-to-back nebulised salbutamol and ipratropium, IV hydrocortisone, and IV magnesium sulphate 2g. After 1 hour, she remains distressed with minimal improvement. SpO2 is 91% on 15L oxygen, heart rate 128/min, respiratory rate 32/min. What is the most appropriate next step?
A. Repeat IV magnesium sulphate 2g
B. Contact ICU for consideration of intubation and ventilation (Correct Answer)
C. Arrange immediate non-invasive ventilation
D. Commence IV aminophylline infusion
E. Commence IV salbutamol infusion
Explanation: ***Contact ICU for consideration of intubation and ventilation***
- The patient presents with **life-threatening asthma** (PEF <33% predicted, SpO2 90% on high-flow oxygen, inability to speak in full sentences, severe tachycardia, tachypnoea) and has failed to respond to **maximal medical therapy**, including repeated nebulized bronchodilators, systemic corticosteroids, and IV magnesium sulphate.
- Persistent distress, minimal improvement, and signs of **impending respiratory failure** (worsening hypoxia despite oxygen, severe tachypnoea, tachycardia) necessitate urgent **airway management** and **mechanical ventilation** requiring **ICU involvement**.
*Repeat IV magnesium sulphate 2g*
- **Magnesium sulphate** is typically administered as a **single dose** (2g) in acute severe asthma; rapidly repeating the dose is not standard protocol due to the risk of **toxicity** (e.g., hypotension, respiratory depression, hypermagnesemia).
- Since the patient remains critically ill with minimal improvement, escalating to **critical care** for definitive airway management is prioritized over repeating an intervention that has already failed to achieve adequate response.
*Arrange immediate non-invasive ventilation*
- **Non-invasive ventilation (NIV)** is generally **contraindicated** in severe acute asthma as it can worsen air trapping, increase the risk of **pneumothorax**, and delay necessary **endotracheal intubation**.
- Guidelines emphasize that patients failing maximal medical therapy in life-threatening asthma require **intubation** and controlled mechanical ventilation rather than NIV, which does not adequately address the dynamic hyperinflation and work of breathing.
*Commence IV aminophylline infusion*
- **IV aminophylline** (a methylxanthine) is considered a **third-line agent** for severe asthma due to its limited additional bronchodilation and a narrow **therapeutic index** with significant potential side effects like arrhythmias and seizures.
- In a patient failing maximal initial therapy with signs of **impending respiratory failure**, starting a slow-acting drug with questionable benefit and potential toxicity is less appropriate than securing the airway and providing **mechanical ventilation**.
*Commence IV salbutamol infusion*
- **IV salbutamol infusion** can be considered in **refractory severe asthma** but should only be initiated under strict monitoring in a **critical care setting** due to significant side effects, particularly **tachycardia** and arrhythmias.
- The patient already has **severe tachycardia** (HR 128-132/min); further systemic beta-agonists would likely worsen cardiac strain without addressing the immediate need for **ventilatory support** for impending respiratory failure.
Question 35: A 76-year-old man is admitted with an exacerbation of COPD. He has severe airflow obstruction (FEV1 32% predicted) and is on home oxygen 2 L/min for 16 hours daily. He is a lifelong smoker, currently smoking 10 cigarettes daily. On admission, he is treated with nebulised bronchodilators, prednisolone 30mg daily, and doxycycline. Arterial blood gas on admission (on 28% Venturi mask) shows: pH 7.35, PaCO2 7.1 kPa, PaO2 8.2 kPa, HCO3- 30 mmol/L. After 24 hours of treatment, repeat blood gas shows: pH 7.36, PaCO2 6.8 kPa, PaO2 8.5 kPa. What should be the target oxygen saturation for this patient?
A. SpO2 85-88%
B. SpO2 94-98%
C. SpO2 92-96%
D. SpO2 88-92% (Correct Answer)
E. PaO2 >10 kPa regardless of saturation
Explanation: ***SpO2 88-92%*** - This patient has **chronic hypercapnia** (Type 2 respiratory failure) as evidenced by an elevated **PaCO2 (7.1 kPa)** and a high **bicarbonate (30 mmol/L)**, which indicates metabolic compensation.- According to **BTS guidelines**, patients with COPD at risk of hypercapnic respiratory failure—including those on **Long-Term Oxygen Therapy (LTOT)** or with an **FEV1 < 50%**—must have a target saturation of **88-92%** to avoid worsening CO2 retention.*SpO2 85-88%* - This range is generally too low and is only occasionally used as a temporary target for patients with **severe hypercapnic respiratory failure** who are not responding to standard management.- Using this target in this patient would risk severe **hypoxemia** and inadequate tissue oxygenation without clear clinical benefit.*SpO2 94-98%* - This is the standard target range for **acutely ill patients** who are not at risk of hypercapnic (Type 2) respiratory failure.- Administering high-concentration oxygen to this patient could diminish the **hypoxic drive**, worsen **V/Q mismatch**, and lead to life-threatening **respiratory acidosis**.*SpO2 92-96%* - This range is sometimes used for patients with **COPD** who have a documented history of being **normocapnic** during acute exacerbations.- Since this patient has clear evidence of **chronic CO2 retention** (high bicarbonate), this target is too high and potentially dangerous.*PaO2 >10 kPa regardless of saturation* - Aiming for a **PaO2 >10 kPa** in a chronic CO2 retainer often requires high-inspired oxygen fractions that significantly increase the risk of **hypercapnia**.- Oxygen therapy should be guided by **peripheral saturations (SpO2)** and blood gases to maintain a balance, rather than pursuing a specific high PaO2 value.
Question 36: A 31-year-old woman presents with a 6-month history of variable wheeze and breathlessness. She works as a hairdresser. Symptoms are worse at work and improve on weekends and holidays. Serial peak flow measurements over 4 weeks show greater than 20% variability between readings at work and at home. What is the most appropriate next step in management?
A. Start regular inhaled corticosteroid and long-acting beta-2 agonist
B. Refer to occupational health for workplace exposure assessment (Correct Answer)
C. Commence oral antihistamines
D. Arrange skin prick testing for common allergens
E. Prescribe salbutamol inhaler as required and review in 3 months
Explanation: ***Refer to occupational health for workplace exposure assessment***- The patient presents with classic features of **occupational asthma**, including a clear temporal relationship between symptoms (wheeze, breathlessness) and the workplace, improvement on weekends/holidays, and significant (>20%) **peak flow variability** between work and home. - Referral to occupational health is the most appropriate next step to identify the specific **sensitizing agent** in her hairdressing environment (e.g., persulphate salts, glutaraldehyde) and facilitate workplace modifications to prevent further exposure and potential irreversible **airway remodeling**.*Start regular inhaled corticosteroid and long-acting beta-2 agonist*- While these medications are standard for chronic asthma management, the priority in suspected **occupational asthma** is **antigen avoidance**, which requires identification of the trigger.- Initiating symptomatic treatment without addressing the underlying cause could mask the problem, delay definitive diagnosis, and potentially lead to a worse long-term outcome.*Commence oral antihistamines*- Antihistamines are primarily effective for symptoms of **allergic rhinitis** or cutaneous allergic reactions.- They do not address the **bronchoconstriction** or underlying airway inflammation characteristic of asthma.*Arrange skin prick testing for common allergens*- While useful for identifying common environmental allergens, this patient's history strongly points to an **occupational trigger**.- Skin prick testing for common allergens might not identify the specific chemicals or agents she is exposed to as a hairdresser, which are more likely to be the cause.*Prescribe salbutamol inhaler as required and review in 3 months*- A **short-acting beta-2 agonist (SABA)** like salbutamol provides only symptomatic relief for acute bronchoconstriction and does not control the **chronic inflammation** of asthma.- Delaying a comprehensive assessment and management plan by 3 months risks ongoing exposure, worsening lung function, and potentially permanent respiratory damage.
Question 37: A 54-year-old woman is admitted with community-acquired pneumonia. She is treated with co-amoxiclav and clarithromycin. On day 4, she develops worsening breathlessness. Chest X-ray shows a new moderate right-sided pleural effusion. Diagnostic pleural aspiration is performed. Analysis shows: pH 6.95, glucose 1.2 mmol/L, LDH 1850 IU/L, protein 42 g/L. Gram stain shows Gram-positive cocci in chains. What is the most appropriate management?
A. Continue antibiotics and repeat chest X-ray in 48 hours
B. Insert a chest drain and continue antibiotics (Correct Answer)
C. Arrange thoracoscopy and decortication
D. Add metronidazole to current antibiotic regimen
E. Change antibiotics to meropenem and vancomycin
Explanation: ***Insert a chest drain and continue antibiotics***
- This patient has a **complicated parapneumonic effusion** or **empyema**, indicated by a **pleural fluid pH <7.2** (6.95), low glucose, and high LDH.
- According to **BTS guidelines**, a chest drain is mandatory if the pleural fluid is purulent, has a **positive Gram stain/culture**, or a **pH <7.2** to prevent loculation and clinical deterioration.
*Continue antibiotics and repeat chest X-ray in 48 hours*
- Antibiotics alone are insufficient because infected pleural fluid does not resolve without **source control** via drainage once the pH drops below 7.2.
- Delaying drainage increases the risk of **pleural thickening**, loculation, and the eventual need for invasive surgery.
*Arrange thoracoscopy and decortication*
- Surgical intervention like **VATS** or decortication is typically reserved for cases where **chest drain drainage fails** or the effusion is heavily multiloculated.
- It is not the first-line management; a trial of **intercostal tube drainage** should be initiated first.
*Add metronidazole to current antibiotic regimen*
- While metronidazole provides **anaerobic coverage**, the Gram stain specifically showed **Gram-positive cocci in chains**, strongly suggesting **Streptococcus species**.
- Adding metronidazole does not address the primary issue, which is the requirement for **mechanical drainage** of the acidic fluid.
*Change antibiotics to meropenem and vancomycin*
- Broadening to **carbapenems** or vancomycin is not indicated as the current regimen (Co-amoxiclav) covers the likely pathogen identified on **Gram stain**.
- Changing antibiotics is secondary to the urgent need for **tube thoracostomy** to drain the infected collection.
Question 38: A 67-year-old man with COPD (FEV1 38% predicted) is admitted with an infective exacerbation. He is treated with nebulised bronchodilators, prednisolone 30mg daily, and doxycycline. On day 3, he develops increasing drowsiness. Arterial blood gas on 28% oxygen shows: pH 7.28, PaCO2 8.2 kPa, PaO2 7.8 kPa, HCO3- 32 mmol/L, BE +6. What is the most appropriate immediate management?
A. Increase oxygen to maintain SpO2 94-98%
B. Start non-invasive ventilation (Correct Answer)
C. Commence doxapram infusion
D. Arrange urgent intubation and mechanical ventilation
E. Reduce oxygen to maintain SpO2 88-92% and repeat blood gas in 30 minutes
Explanation: ***Start non-invasive ventilation***- This patient is in **acute hypercapnic respiratory failure** (pH 7.28, PaCO2 8.2 kPa) secondary to a COPD exacerbation, complicated by increasing **drowsiness**, which is a sign of worsening CO2 narcosis and indicates the need for ventilatory support.- **Non-invasive ventilation (NIV)** is the first-line treatment for acute hypercapnic respiratory failure in COPD, shown to improve gas exchange, reduce work of breathing, and decrease the need for invasive mechanical ventilation and mortality.*Increase oxygen to maintain SpO2 94-98%*- Providing high-concentration oxygen to a patient with **COPD and hypercapnia** can abolish the **hypoxic drive** and worsen **V/Q mismatch**, leading to further retention of CO2 and exacerbation of acidosis.- The target oxygen saturation for most COPD patients at risk of hypercapnia is **88-92%**, not 94-98%, to minimize the risk of worsening hypercapnia.*Commence doxapram infusion*- **Doxapram** is a respiratory stimulant that has largely been superseded by **NIV** due to its less effective respiratory support and potential for side effects.- It does not provide the direct mechanical ventilatory assistance required to overcome severe **hypercapnic respiratory failure** and improve gas exchange as effectively as NIV.*Arrange urgent intubation and mechanical ventilation*- **Intubation and mechanical ventilation** are typically reserved for patients who fail a trial of NIV, have contraindications to NIV (e.g., inability to protect airway, severe encephalopathy, cardiorespiratory arrest), or present with life-threatening acidosis (often pH < 7.25 and rapidly deteriorating).- Given the patient's current pH and clinical status, a trial of **NIV** is the more appropriate initial step before resorting to invasive ventilation.*Reduce oxygen to maintain SpO2 88-92% and repeat blood gas in 30 minutes*- While titrating oxygen to maintain an SpO2 of **88-92%** is correct for COPD patients, simply reducing oxygen alone is insufficient to manage severe **acute hypercapnic respiratory failure** with associated acidosis and drowsiness.- This approach delays crucial ventilatory support (NIV) that is immediately needed to correct the acidosis and prevent further clinical deterioration and potential respiratory arrest.
Question 39: A 42-year-old man with known severe asthma is reviewed in the respiratory clinic. Despite treatment with high-dose ICS/LABA (fluticasone 500 micrograms/salmeterol 50 micrograms twice daily), montelukast 10mg daily, and a maintenance and reliever therapy regimen, he continues to have frequent exacerbations requiring oral corticosteroids every 2-3 months. Blood tests show peripheral eosinophil count 520 cells/μL. FeNO is 68 ppb. What is the most appropriate next step in management?
A. Add oral theophylline
B. Refer for consideration of biologic therapy (Correct Answer)
C. Increase ICS dose to fluticasone 1000 micrograms twice daily
D. Add tiotropium bromide
E. Commence long-term low-dose oral prednisolone
Explanation: ***Refer for consideration of biologic therapy***
- This patient has **severe uncontrolled asthma** despite high-dose ICS/LABA, montelukast, and MART, with clear evidence of **Type 2 inflammation** shown by a **peripheral eosinophil count of 520 cells/μL** and **FeNO of 68 ppb**.
- Referral for specialist assessment for **biologic therapies** (e.g., mepolizumab, benralizumab, dupilumab) is the most appropriate next step to target this inflammation, reduce exacerbation frequency, and minimize oral corticosteroid use.
*Add oral theophylline*
- **Theophylline** is a weak bronchodilator with a narrow therapeutic index and significant potential for side effects, making it a less preferred option for severe uncontrolled asthma, especially when potent, targeted therapies are available.
- It primarily provides bronchodilation and does not effectively address the underlying **Type 2 eosinophilic inflammation** driving this patient's persistent symptoms and exacerbations.
*Increase ICS dose to fluticasone 1000 micrograms twice daily*
- The patient is already on a **high-dose ICS** (fluticasone 500 micrograms twice daily, equivalent to 1000 micrograms daily). Further increasing the ICS dose beyond this point typically yields diminishing clinical returns and significantly increases the risk of **systemic corticosteroid side effects**.
- Guidelines recommend escalating to targeted therapies like biologics in patients who remain uncontrolled on maximal conventional ICS doses, particularly with clear inflammatory biomarkers.
*Add tiotropium bromide*
- While adding a **Long-Acting Muscarinic Antagonist (LAMA)** such as tiotropium can be a valid step-up therapy in asthma, it primarily offers additional bronchodilation.
- In this patient with prominent **Type 2 inflammatory markers** and frequent exacerbations despite maximal conventional therapy, biologic therapy is a more targeted and effective approach to modify the disease process itself, rather than just symptom management.
*Commence long-term low-dose oral prednisolone*
- Long-term **oral corticosteroids** are associated with numerous serious adverse effects including **osteoporosis, diabetes, hypertension, and adrenal suppression**.
- Given the availability of effective **steroid-sparing biologic agents** for severe eosinophilic asthma, commencing long-term oral prednisolone should be a last resort and explored only after biologics have been considered and failed.
Question 40: A 37-year-old woman presents with sudden onset breathlessness and right-sided pleuritic chest pain. She returned from Australia 3 days ago after a 24-hour flight. She takes the combined oral contraceptive pill. On examination, heart rate 102/min, blood pressure 132/78 mmHg, respiratory rate 24/min, SpO2 93% on room air. ECG shows sinus tachycardia. D-dimer is 850 ng/mL (normal <500). Her two-level Wells score for PE is calculated. Which clinical feature is NOT part of the two-level Wells score for pulmonary embolism?
A. Clinical signs of deep vein thrombosis
B. Heart rate greater than 100 beats per minute
C. Immobilisation or surgery in previous 4 weeks
D. Haemoptysis
E. Oxygen saturation less than 95% on room air (Correct Answer)
Explanation: ***Oxygen saturation less than 95% on room air***
- **Oxygen saturation** is an important clinical parameter, but it is **not included** as a metric in the calculation of the Wells score.
- The Wells score focuses on **clinical history**, physical findings, and the likelihood of alternative diagnoses rather than physiological markers like pulse oximetry.
*Clinical signs of deep vein thrombosis*
- This is a major component of the score, carrying the highest weight of **3 points** for signs like **unilateral leg swelling** or tenderness.
- Its presence significantly increases the clinical probability of an underlying **venous thromboembolism**.
*Heart rate greater than 100 beats per minute*
- **Tachycardia** is a recognized indicator of physiological stress from a PE and contributes **1.5 points** to the score.
- It is a common clinical finding but is **non-specific**, which is why it receives fewer points than clinical DVT.
*Immobilisation or surgery in previous 4 weeks*
- This identifies a significant risk factor for **venostasis**, contributing **1.5 points** if the patient was immobilized for 3 or more days or had surgery.
- Recent **prolonged travel** (as seen in this patient) often prompts the assessment of this specific criteria.
*Haemoptysis*
- The coughing up of blood is a clinical sign of **pulmonary infarction** and earns **1 point** in the Wells criteria.
- While less frequent than chest pain or dyspnea, its presence increases the **pre-test probability** of a pulmonary embolism.
